ATDEPARTMENT OF HEALTH AND HUMAN SERVICES
UNITED STATES FOOD AND DRUG ADMINISTRATION
CENTER FOR DRUG EVALUATION AND RESEARCH
ADVISORY COMMITTEE FOR REPRODUCTIVE
HEALTH DRUGS
Monday, September 29, 2003
8:35 a.m.
Hilton Hotel
The Ballrooms
620 Perry Parkway
Gaithersburg, Maryland
PARTICIPANTS
Linda C, Giudice, M.D., Ph.D.,
Chairman
Shalini Jain, PA-C, M.B.A., Executive Secretary
MEMBERS
Susan Crockett, M.D.
W. David Hager, M.D.
Nancy W. Dickey, M.D.
George A. Macones, M.D.
Joseph B. Stanford, M.D.
Scott S. Emerson, M.D., Ph.D.
Vivian Lewis, M.D.
Larry Lipshultz, M.D.
Valerie Montgomery Rice, M.D.
SPECIAL GOVERNMENT EMPLOYEE VOTING CONSULTANTS
Robert G. Brzyski, M.D., Ph.D.
Adelina M. Emmi, M.D.
David L. Keefe, M.D.
Lawrence C. Layman, M.D.
James H. Liu, M.D.
James P. Toner, Ph.D.
ACTING CONSUMER REPRESENTATIVE
Lorraine J. Tulman, D.NSc.
FDA
Daniel Shames, M.D.
Shelley R. Slaughter, M.D., Ph.D.
Audrey Gassman, M.D.
C O N T E N T S
Call to Order and Opening Remarks:
Linda Giudice,
M.D., Ph.D. 4
Conflict of Interest Statement:
Shalini Jain, PA-C,
M.B.A. 6
Opening Remarks:
Daniel Shames, M.D. 9
Ovulation Induction and Assisted Reproductive
Technology--Background and Practice:
David L. Keefe,
M.D. 11
Questions from the Committee 34
Gonadotropins in ART:
James P. Toner,
M.D., Ph.D. 73
Questions from the Committee 116
Human Gonadotropins--Regulatory History:
Shelley R.
Slaughter, M.D., Ph.D. 147
Questions from the Committee 158
Open Public Hearing
Dr. Robert Kirsch 173
Dr. Kurt Barnhardt 179
Mr. Sean Tipton 185
Presentation of Questions and Committee
Discussion 190
P R O C E E D
I N G S
Call to Order and Opening Remarks
DR.
GIUDICE: Good morning. I would like to begin our meeting this morning. This is the FDA Advisory Committee for
Reproductive Health Drugs. I am Linda
Giudice from Stanford University and I
am the Chair of the Committee. Today, we
will have a general discussion and tomorrow we will have a product-specific
discussion with Sorono.
Some
housekeeping issues before we have introductions of the committee members. Please, if you would turn your cell phones
and beepers off or at least put them on "Silent" so that the
proceedings are not disturbed. Rest
rooms are down towards the main desk.
So
I would like to begin with introduction of the committee members and perhaps we
can start on this side with Dr. Hager.
DR.
HAGER: David Hager, University of
Kentucky.
DR.
CROCKETT: I am Susan Crockett and I am
from Christus Santa Rosa in San Antonio, Texas.
DR.
MACONES: George Macones from the
University of Pennsylvania in Philadelphia.
DR.
LEWIS: Vivian Lewis from the University
of Rochester.
DR.
TULMAN: Lorraine Tulman, University of
Pennsylvania, Consumer Representative.
DR.
LIPSHULTZ: I am Larry Lipshultz from
Baylor College of Medicine in Houston.
DR.
KEEFE: David Keefe from Women and
Infants Hospital and Brown in Providence, Rhode Island.
DR.
DICKEY: Nancy Dickey from Texas A&M
Health Science Center in College Station.
MS.
JAIN: Shalini Jain, Executive Secretary
to the Advisory Committee for Reproductive Health Drugs.
DR.
EMERSON: Scott Emerson from the
University of Washington in Seattle.
DR.
EMMI: Adelina Emmi from Medical College
of Georgia.
DR.
STANFORD: Joseph Stanford from the
University of Utah, Salt Lake City.
DR.
BRZYSKI: Robert Brzyski from U.T. Health
Science Center, San Antonio.
DR.
TONER: Jim Toner, Atlanta Center For
Reproductive Medicine.
DR.
RICE: Valerie Montgomery Rice, Meharry
Medical College.
DR.
GASSMAN: Audrey Gassman from the FDA.
DR.
SLAUGHTER: Shelley Slaughter from the
FDA.
DR.
SHAMES: Dan Shames, FDA.
DR.
GIUDICE: Thank you very much. Dr. Layman just walked in.
DR.
LAYMAN: Hi. Larry Layman, Medical College of Georgia.
DR.
GIUDICE: Thank you.
I
would like to introduce now Shalini Jain who will talk about the
conflict-of-interest statement.
Conflict of Interest Statement
MS.
JAIN: Thank you, everyone, for
participating today. I would like to
read the conflict-of-interest statement for the Advisory Committee for
Reproductive Health Drugs for September 29, 2003.
"The
following announcement addresses the issue of conflict of interest with respect
to this meeting and is made a part of the record to preclude even the
appearance of such at this meeting. The
committee will discuss issues relevant to the conduct of clinical trials and
outcome measures for consideration of approval of drug products for the
indications of induction of ovulation and pregnancy in anovulatory infertile
women and development of multiple follicles, and pregnancy and ovulation women
participating in assisted reproductive technology, or ART, programs.
The
topic of today's meeting is an issue of broad applicability. Unlike issues before a committee in which a
particular product is discussed, issues of broader applicability involve many
industry sponsors and academic institutions.
All
special government employees have been screened for their financial interests
as they may apply to the general topics at hand. Because they have reported interests in
pharmaceutical companies, the Food and Drug Administration has granted
general-matters waivers to the following SGEs which permits them to participate
in today's discussions; Dr. Scott Emerson, Dr. W. David Hager, Dr. Larry
Lipshultz, Dr. Valerie Montgomery Rice, Dr. Susan Crockett, Dr. Adelina Marie
Emmi and Dr. James Liu.
A
copy of the waiver statements may be obtained by submitting a written request
to the agency's Freedom of Information Office, Room 12A-30 of the Parklawn
Building. Because general topics impact
so many institutions, it is not prudent to recite all potential conflicts of
interest as they apply to each member and consultant.
FDA
acknowledges that there may be potential conflicts of interest but, because of
the general nature of the discussion before the committee, these potential
conflicts are mitigated. In the event
that the discussions involve any other products or firms not already on the
agenda for which an FDA participant has a financial interest, the participants
are aware of the need to exclude themselves from such involvement and their
exclusion will be noted for the record.
With
respect to all other participants, we ask, in
the interest of fairness, that they address any current or previous
financial involvement with any firm whose products they may wish to comment
upon.
Thank
you.
DR.
GIUDICE: Thank you.
I
would now like to introduce our first speaker, Dr. Daniel Shames, who is the
Director of the Division of Reproductive and Urologic Drug Products at the FDA.
Opening Remarks
DR.
SHAMES: Thank you. I would first like to welcome everybody this
morning and I would like thank Dr. Giudice and all our advisors and consultants
and speakers for taking time out of their busy schedules to educate us about
the issues surrounding the use of drugs for the treatment of female
infertility.
I
would also like to take this opportunity to thank the two members of our
division that were most responsible for assembling and producing the elements
of what I believe will be a very exciting forum. Both are fully trained and certified
reproductive endocrinologists and the division is fortunate to have them. Thank you to Dr. Shelly Slaughter and Audrey
Gassman.
In
our division, we regulate a diverse group of drug products for such indications
as advanced prostate cancer, sexual dysfunction, post-menopausal therapy,
incontinence, BPH, among others. I must
say that, among all the indications that we deal with, I find female
infertility the most challenging from a clinical-trial-design, scientific and
regulatory perspective.
As
you know, FDA approves for marketing safe and effective drugs. Safety and effectiveness are demonstrated by
adequate and well-controlled clinical investigations. Science and drug development have considerably
advanced using randomized, blinded, controlled-trial design. The randomized clinical trial has
revolutionized our view of what are effective treatments for many diseases such
as cancer therapy and heart disease.
For
female infertility, we want to make sure we provide the public with drugs that
are safe and effective. This is
accomplished by the provision of evidence from properly designed and conducted
trials. The complex nature of clinical
treatment protocols and the rapidly changing technologies and pharmacotherapy
makes it a challenge to establish standards for insuring that clinical trials
of drugs for female infertility are appropriate.
There
is an overriding charge for the assembled experts attending today and
tomorrow. This charge is to inform the
division regarding elements that must be incorporated into clinical trials for
pharmacologic therapy of infertile women so that these trials will provide the
level of evidence needed to conclude that these therapies are, indeed, safe and
effective.
With
this information and input from all appropriate sources including the
pharmaceutical industry, the division will write a guidance for the clinical
evaluation of drugs in this area resulting in more rapid and efficient
development of pharmacologic therapy for female infertility.
Thank
you.
DR.
GIUDICE: Thank you very much.
We
now have a guest speaker, Dr. David Keefe, who will talk to us--who is the
Director of the Reproductive Medicine and Infertility Unit at Women's and
Infant's Hospital in Rhode Island. He
will talk to us on Ovulation Induction and Assisted Reproductive Technology,
Background and State of the Art.
Dr.
Keefe.
Ovulation and Assisted Reproductive
Technology
Background and State of Practice
DR.
KEEFE: Great.
[Slide.]
Thank
you, Dr. Giudice and thank you for the opportunity to come here today and share
in this very important forum.
[Slide.]
There
are a number of aspects to my presentation.
I am going to give an overall introduction to the ART procedures and, in
particular, in vitro fertilization and comment in particular how they relate to
the issues of study design, particularly the study population, study design and
then, hopefully, give you a sense of what I think is the future of ART,
particularly the issue of ART outcomes.
[Slide.]
Assisted
Reproductive Technologies actually encompass a variety of different
techniques. The one most commonly
practiced in the United States is in vitro fertilization with embryo transfer. It is a little bit of a misnomer to call it
in vitro fertilization because probably the most crucial part is the actual
implantation which follows. But
convention calls it in vitro fertilization.
In
addition, gamete intrafallopian transfer is a variation on this theme in which
the gametes are placed in the fallopian tubes or placed after the fertilization
has actually occurred, zygote
intrafallopian transfer or tubal-embryo transfer.
These
three are almost of historic interest because they are not widely practiced. There are rare indications and I am not going
to discuss controlled ovarian hyperstimulation with intrauterine inseminations
which some would put under the rubric of assisted reproductive technologies. Rather I am going to focus most of the
discussion this morning on in vitro fertilization, the most widely practiced of
the assisted reproductive technologies in the United States.
[Slide.]
The
first step is to downregulate the ovaries, typically done with oral
contraceptive pills or progesterone with gonadotropin-releasing hormone
agonists or antagonists, to first try to synchronize the follicular cohort
since the idea is to superovulate the woman.
The controlled ovarian hyperstimulation step is typically done with
gonadotropins and monitored with a number of ultrasound and estradiol levels.
Next,
after the ultrasounds and estradiols have identified a size of follicle and an
estradiol level consistent with oocyte maturation within the follicle, then hCG
human chorionic gonadotropin is used to trigger maturation largely because hCG
serves as a kind of a surrogate for luteinizing hormone, the physiologic
trigger of oocyte maturation. Just
practically hCG has a much longer half-life and is more practical, at least
under current technologies.
Retrieval
is done under general sedation and then fertilization is typically performed
transvaginally. Fertilization is
effected either with an incubation with the gametes in the test tube or through
direct injection of the sperm through intracytoplasmic sperm injection.
Next,
the embryos are cultured for a number of days, between two and six days,
depending on protocols, particularly under the indications of the patient. The embryos, then, are transferred through a
very non-invasive procedure in which a very small flexible catheter is used to
place the embryos up into the uterus, typically without but occasionally with a
hatching procedure in which the shell, the zona pellucida, around the embryos
is first thinned or breached.
Next,
and finally, the luteal phase, that second half of the menstrual cycle, is
supplemented since the retrieval had aspirated a number of the follicular cells
and the gonadotropin-releasing-hormone agonists or antagonists may have shut
down their ability to produce progesterone adequately initially. So progesterone is administered either
vaginally or intramuscularly for a number of days.
[Slide.]
So
just an overview here. You have the
follicle stimulation. I think this gives
you a sense of the time frame. This is a
very drawn-out procedure which may go up to six weeks for an individual single
cycle in which these follicles are stimulated with gonadotropins after
downregulation and then the mature eggs are removed with a 15 or 20-minute
aspiration under general sedation.
Then
the eggs and sperm are joined together in the fertilization step and the embryo
is cultured. So it gives you a sense of
the drawn-out nature of this procedure which is, I think, particularly
challenging for the couples going through--when the woman often is working or
has a life outside the IVF cycle.
[Slide.]
The
in vitro fertilization step also involves a number of laboratory procedures,
and each of them provides a potential for an outcome; the number of eggs
retrieved. The next step is that the
eggs are stripped and they have to be equilibrated in the culture media. And then fertilization, how effectively was
that performed?
Then
the incubation provides at least up to six days when each of the steps of
embryo development can be monitored in vitro.
So these processes can be broken down and a number of metrics can be
applied to each, useful for outcome studies if one is evaluating the efficacy
of the various medications that are used.
[Slide.]
Controlled
ovarian hyperstimulation is going to be dealt with by the next speaker in much
more detail, but you can see at least these two commonly used protocols, the
GnRH agonists protocol, first.
This
is the one down below, the lower in the panel here, in which this agonist is
administered in the luteal phase of the preceding cycle that we are actually
going to move forward on the aspiration.
Because there is an initial stimulatory effect, the luteal phase is the
most refractory phase of the menstrual cycle to gonadotropins. This flare effect is masked by the high
levels of progesterone in the luteal phase of the antecedent cycle and then
allowed to move, five to seven days later, into the suppressive phase when,
then, the stimulation can begin and then, finally, the hCG trigger.
The
antagonists are direct inhibitors of the GnRH receptor and, therefore, do not
need to be preceded by--or administered in the preceding luteal phase. Instead, the gonadotropins are initiated at
the beginning of the cycle directly and then the antagonist is added later
towards the mid-portion to later portion of the sort of mock follicular phase
finally hCG is triggering. So you can
see at each point along the way, a number of potential markers.
[Slide.]
With
regard to how we evaluate studies now, the study populations that are used, it
is really important to note that there are--each of these procedures done, in
vitro fertilization, intracytoplasmic sperm injury in donor egg, are very, very
different. These are different
procedures but they are administered in very different patients. So it is very problematic to group data from
each of these.
[Slide.]
They
really reflect quite different pathology.
The diseases that are being treated with these oftentimes are not even
reflected in the diagnosis that may appear in the chart. Intracytoplasmic sperm injection implies,
therefore--you know, it is a very significant sperm problem and assumes,
oftentimes, that there is a normal egg complement although that also may be a
concomitant problem.
Donor
egg, at least when it is administered on the recipient side, means presumably
the eggs are actually quite healthy. So
there is a major difference in egg dysfunction with in vitro fertilization
having a higher likelihood of poor egg reserve and function, more than
intracytoplasmic sperm injection, and egg donation, of course, would have the
least likelihood of having dysfunctional eggs.
Indeed,
egg dysfunction, also known as ovarian reserve and very crudely estimated by
the chronological age of the woman, is the best predictor in virtually every
study that has ever been published on the outcome of in vitro fertilization,
more important than the diagnosis, more important, oftentimes, than the
chronologic age, itself.
Indeed,
there are log-order differences in pregnancy rates among groups of patients
from a woman who is in her mid-40s with a diagnosis, say, of tubal disease as
opposed to a woman in 20s. And there may
be women who are matched by age but exhibit markedly different
reproductive-aging markers.
So
egg dysfunction underlies much of the outcome and has to be very carefully
controlled in any studies, either through inclusion-exclusion criteria, case
control or stratification.
[Slide.]
There
are a number of issues regarding study design, particularly efficacy measures
and the question of how we should define success and what are safety endpoints
are also quite important in evaluating in vitro fertilization and the status of
IVF today.
[Slide.]
Of
course, deliveries, the number of babies that actually come out of a study, the
cycles that were initiated, is the gold standard in any study. But this is, as you can imagine, costly and
the power needed to show differences when you have something that is happening
20percent to 50 percent of the time is quite large.
So
a number of surrogate clinical outcomes, as well as surrogate biological
outcomes, are frequently employed in studies.
Ongoing viable pregnancies and clinical pregnancy rates, which is
essentially a sac with a fetal heart detectable, are widely used as is
biochemical pregnancy rate which is the very earliest marker of a pregnancy
even before the sac or the fetal heart is detectable, typically with just the
beta hCG rising appropriately, are widely used.
The
surrogate biological outcomes that have been employed in studies include the
number of follicles, the peak estradiol, the number of eggs that are aspirated
and the fertilization rate as well as the embryo cleavage and morphology rates.
[Slide.]
The
deliveries per initiated cycle, of course, is the gold standard but you need
huge power to show differences between a study that--in a study where the
expected outcome is 30 percent. This
makes is very expensive. It is also
difficult to measure, at times, but it is important because there may be huge
patient-specific differences in groups that are oftentimes subtle and not
obviously reflected in simple things like the FSH or the age.
[Slide.]
The
surrogate clinical outcomes are closer to the gold standard than the purely
biological ones. You need much less
power because of this, but they are clinically important outcomes as well. There are differences, though, in miscarriage
rates according to protocols as well as with patients that may make it less
than desirable, less than the optimal.
They
also may be contaminated heavily by clinical practices. For example, clinics vary significantly in
their level of cancellation, the criteria they will use to not allow a patient
to go to transfer or not even to start a patient or, once they are started, to
cancel them. So there can be a lot of
confounders in any studies and these are ones that clinicians have been very
careful to evaluate themselves when they look at the study.
[Slide.]
Looking
at biological outcomes, they are quite distant from the gold standard of the
pregnancies per cycle started but much more sensitive. They may not reflect really clinically
important outcomes. For example, there
are many women that have a low response to controlled ovarian hyperstimulation
but they still have excellent outcomes.
So
if you were using just peak estradiol or the number of eggs in a 25-year-old,
that is something very, very different than if she is a 45-year-old. There are subtle differences, as well, in
drug potencies on egg yield in estradiol that may be interesting and
significant statistically but not so important clinically because you just
manage that by changing the dosing.
[Slide.]
So
how should success be defined with assisted-reproductive-technology
studies? It has been proposed that there
should be placebo controls. It is a
little hard to do that in a situation in which, say, somebody is going through
in vitro fertilization because they have blocked tubes.
[Slide.]
Rather,
I think success should be defined according to the pregnancy rate but also
according to a number of other issues which include things like convenience and
discomfort level. The pregnancy rate is
important but there are a number of other factors.
You
saw, at the beginning, when I discussed the IVF proposals, how complex and time
consuming they are. So a study which
showed equivalence but convenience, as one of the outcomes, was superior in one
of the arms could actually be a superior product. So convenience and discomfort are very
important.
[Slide.]
The
other issue is that, with regard to the importance of accepting sort of
noninferior or equivalent drugs, is that we really need competition in this
area. There are also a number of
patient-specific preferences. Options in
allowing patients to choose would be enhanced.
There would be an enhanced sort of customer satisfaction.
For
example, some patients prefer vaginal-route progesterone over intramuscular
administration of progesterone, or vice-versa.
So it is important to have variation and different options available for
administration routes and other factors.
An
example of this would be, as I mentioned, the vaginal progesterone versus
intramuscular and, of course, the differences in the number of days that the
agonist is administered versus the antagonist.
I showed you at the beginning the very long cycle that the agonist
requires and the antagonist shortens that.
So,
just look at pregnancy as the only outcome would really miss important factors
because of the time cost and the convenience cost and the comfort cost that
couples accrue, particularly the woman, as they proceed through IVF.
[Slide.]
Safety
endpoints conventionally include the ovarian hyperstimulation syndrome,
miscarriage, multiple pregnancy rate and ectopic pregnancy rate. Because ectopic are so rare with IVF, I won't
even discuss them.
[Slide.]
But,
obviously, ovarian hyperstimulation--this is a life-threatening condition,
potentially life-threatening condition, in which some factor emitted from the
ovaries, secreted from the ovaries, confers a vascular permeability throughout
the body of the woman and can lead to ascites, large accumulation of fluid in
the abdominal cavity, pleural effusions,
instabilities in the hemodynamic system as well as increased coagulation. There have actually have been a number of
deaths, strokes, loss of limbs from clotting and vessels.
So
this really sets the upper limit on the controlled ovarian hyperstimulation
that the woman is going through for in vitro fertilization. There is a pretty good correlation between
the amount of stimulation, the number of eggs, the peak estradiol, sort of the
number of lottery tickets we buy each time we put the woman through IVF and
this sets the upper limit.
It
constrains how high you can go. The risk
may be modified by lowering those peak estradiols. A number of examples include recent
introduction of aromatase inhibitors and luteinizing hormone which may alter
the peak estradiol and alter some of the estradiol-related molecules, vascular
endothelial growth factor, and so on, that may be mediating the risk for
control of ovarian hyperstimulation.
So
it may alter those, but not alter the success rate. And that would be a big win.
[Slide.]
Miscarriage
is a very common occurrence following assisted reproduction as well as
following any pregnancy. It is quite
common, even in young women going through IVF.
Up to 15 percent of them undergo a miscarriage after conception. In older women, women who are in their early
40s, up to 70 percent of their pregnancies will end as a miscarriage.
These
rates are highly affected by patient-specific factors--for example, the age of
the woman, her ovarian reserve--but also could be influenced by a number of
stages of the assisted reproductive technology that she is undergoing. The stimulation regimens theoretically could
influence the risk of miscarriage.
Particularly overstimulation with luteinizing hormone has been shown to
disrupt developmental potential of the embryos, disruption of the normal
luteal-phase support as well as a number of laboratory-related processes that
we are not discussing this morning, the culture media.
So
this is a very important endpoint.
[Slide.]
Multiple
gestations are major risks for IVF. It
is very common, between 15 and 50 percent, depending on the aggressiveness of
the center. There are, of course, major
obstetric pediatric and public-health concerns from multiple gestations
including prematurity. Cerebral palsy
risk is increased threefold with twins and twelvefold with triplets, Caesarian
section rate from almost 100 percent with triplets to 40 to 50 percent with
twins, preeclampsia, gestational diabetes.
The list goes on. This is a major
risk which has actually reached public-health proportions.
It
is affected by patient-specific factors; for example, her age and her ovarian
reserve. It is affected by rather
illusive clinician practices, the number of viable embryos transferred. It is obvious that the doctor is very
committed to optimizing the success rate, not only for the patient but for his
or her own center, and it is a very tricky thing to figure out exactly how many
embryos to balance the needs of the couple going through the procedure versus
the bigger concern about preventing multiple gestations.
Of
note, monozygotic twinning is also increased significantly after all forms of
assisted reproductive technology, not just after IVF, not just after blastocyst
transfer, but even after clomiphene citrate ovulation and gonadotropin
ovulation and induction. This is a real
significant problem as well. While it is
not anywhere near as common, it approaches 3 to 4 percent in some IVF practices
including blastocyst transfer as opposed to the 1 in 800 baseline.
It
is a significant cause of morbidity because of the twin-twin transfusion
syndrome that can result from a monozygotic twin; that is, where a single
zygote or embryo later has split. It is,
by the way, more difficult to control through modifying the number of embryos
transferred because you could put in one embryo and still end up with
monozygotic twins.
A
number of other developmental anomalies are just sort of appearing on the
horizon. It is more of a question of
whether some of these should be included as potential risk factors or safety
concerns with assisted reproductive technology.
I think it really just requires more studies before we conclude about
their importance.
But
imprinting abnormalities, and particularly the Beckwith-Wiedemann syndrome and
Angelmann syndromes have been implicated in complications of IVF. Pregnancy-induced hypertension is increased even when you
control for multiparity following in vitro fertilization and Baha Subai and
others have argued that one of the etiologies of pregnancy-induced hypertension
is an imprinting abnormality.
So
I think we just need more data before we know.
They tend to be quite rare to begin with so it is a little hard to know
to what extent what we are seeing is a detection bias.
[Slide.]
Finally,
just to look into the future of where IVF is going and, particularly,
assessment of IVF, we really do need more randomized clinical trials.
[Slide.]
We
need multicenter networks doing these randomized clinical trials. I think those of us who deal with menopause
patients are just overwhelmed by the impact of the Women's Health Initiative on
our clinical practice and why can't we get this far in fertile patients. They deserve it. There should be more randomized clinical
trials to answer these questions.
In
addition, we need more racial and ethnic diversity in our clinical studies to
ensure generalizability, particularly as mandates for in vitro fertilization
coverage spread across the country. I
work in two states, Massachusetts and Rhode Island, where we have a mandate and
it is really gratifying to see couples from all walks of life coming through
our practice, not just very wealthy investment bankers, doctors and lawyers.
[Slide.]
In
addition, we need to improve biological surrogate markers. I think is going to come before the other
two. In particular, aneuploidy is
ubiquitous and it is related to assisted reproductive failure. There is increased embryo apoptosis or cell
death. There is implantation failure and
miscarriage from aneuploidy that is abnormal chromosome number.
This
could, then, provide a meaningful biological surrogate for outcomes. In addition, a number of safety problems in
in vitro fertilization stem from attempts to overcome egg dysfunction and its
core aneuploidy through controlled ovarian hyperstimulation. Essentially, what we are doing is we are
pushing harder and harder to get more and more eggs in the hopes that we will
find one or two, and then we will put more and more in until we finally find
the right one.
But
if we could figure out which of those embryos are the developmentally competent
ones up front, we would avoid much of that.
There is some evidence that controlled ovarian hyperstimulation, itself,
may predispose to aneuploidy by shortcutting sort of the normal selection
process of follicles and by altering the follicular environment.
There
are a number of new technologies on the horizon to diagnose aneuploidy which
will make it practical. Just to give you
an example, many of the studies we read in the literature will use high-quality
embryos, or healthy-appearing embryos or viable embryos as a marker, an outcome
measure.
[Slide.]
This
just shows you a number of photomicrographs of a healthy-appearing embryo that,
on Day 3, was diagnosed with trisomy 21 by preimplantation genetic diagnosis
with normal development of blastocyst.
Indeed, there is some evidence that certain trisomies are more likely to
reach blastocyst than others suggesting that blastocyst development culture in
vitro to this later stage of Day 5 or 6 is not the answer and, as we know, it
also may introduce other complications through enhanced stress on the embryo.
[Slide.]
Preimplantation
genetic diagnosis is probably going to improve the implantation rate. This is a study from Gianaroli showing a
doubling of the implantation rate when he prescreened them with a set of nine
probes. It seemed to predict the
outcome.
[Slide.]
Here
patients had failed IVF three times and were, then, submitted to
preimplantation genetic diagnosis and were either found to have no one or a
greater than one normal embryo with these limited number of probes.
[Slide.]
You
can see, at each point, an increase, a significant increase, in the birth per
patient suggesting, again, that this is going to be key. Tony Pellicer in Valencia showed that you
could also reduce the pregnancy loss in IVF patients that he had gone through.
[Slide.]
Gonadotropins
are key to this. This is where
evaluating gonadotropins and how well they do, we know that it is the
gonadotropins that, of course, when we stimulate the immature follicles,
develop and it is these spindles within the eggs that are teasing apart the
chromosomes here at metaphase 1 lined on the metaphase plate. This is when the aneuploidy first appears.
[Slide.]
You
can see that there are abnormal spindles.
This is a shameless self-promotion of my own research here for a moment,
if you will--you can see abnormal spindles by Battaglia in these eggs from
abnormal spindles.
[Slide.]
This
just shows that we can actually image this noninvasively using some pole
technology that we were involved with and, by doing this, demonstrate improved
development and improved pregnancy rate when we do this noninvasive
investigation of the egg quality.
[Slide.]
In
addition, there is a new area that we are working on in which we look at some
of the chromosome structure and its propensity to aneuploidy and we have shown
a number of factors that predispose to chromosome abnormalities in embryos that
can be predicted by this biological marker.
So,
in summary, then, in vitro fertilization is improving. We have got still a very complex
proposal. We need it to be
simplified. We need studies that show
which of the better drugs--that use randomized clinical trials. In the meantime, we need to continue to
improve these shorter-term biological markers as surrogates.
Thank
you.
DR.
GIUDICE: Thank you, Dr. Keefe.
Questions from the Committee
The
committee now has several minutes to ask questions of Dr. Keefe, if there are
any. While people are gathering their
thoughts, David, I would like to ask you if you could please comment upon the
issues and challenges of placebo control in ART treatment and also the issue of
blinding.
DR.
KEEFE: Okay. The issue of placebo control is problematic
in ART for a number of reasons. In
particular, a number of the treatments that we now use in in vitro
fertilization have already been demonstrated to be better than nothing. For example, the Canadian study has shown
that untreated infertility, unexplained infertility, over the course of five
years while Canadians were waiting to get into the Canadian health system had
an expected fecundity of around 2 percent per month, which is significantly
less than what we experience through most of these treatments.
In
addition, a number of diagnoses for which we now use in vitro fertilization
would be expected to have a zero percent pregnancy rate, especially
completely blocked, occluded fallopian tubes.
Finally, those with severe male-factor infertility in which there is no
sperm, azoospermia, in which the sperm has to be extracted from the testicle and
has essentially zero motility, or very low motility, and is only going to get
into the egg through a direct injection route, I think it would be unethical to
use a placebo.
I
think in other areas, where there is questionable value, you can imagine the
utility of a placebo. Unexplained infertility
when everything else seems to be working but there is no pregnancy is one
example, a 2.5 percent pregnancy rate per month. I think that is one area where there might be
some use of it, but, for the most part, especially for in vitro fertilization,
I think it would be better to use existing technology as the control and then
add in the additional.
And
then the second was a placebo and then blinding? Blinding is difficult for in vitro
fertilization compared to placebo, obviously, but, for in vitro fertilization
with Treatment A as opposed to Treatment B, it is very reasonable. Blinding, of course, is a fundamental study
design and is always desirable.
I
don't think that there is much impact of blinding on the patient side. I don't think there is much of a placebo
effect here but, certainly, on the clinician side where you can see the
complexity of the treatment regimens, where there is a great potential for
confounders to be introduced in terms of the way the cycle is handled, it is a
very valuable strategy to be able to control for those potential confounders in
which the doctors may be treating differently the treatment versus the control
group. So I think blinding would be very
valuable, particularly with medications in which there is a potential to treat
according to what you think might be the best or the more desirable way.
So
I think both blinding on the patient and the doctor side was desirable
although, obviously, on the doctor side of it is more important.
DR.
GIUDICE: I think we all realize--
DR.
KEEFE: There is a question. Do you have a question?
DR.
GIUDICE: I think we also all realize,
though, that in doing an ovulation induction cycle or ovulation enhancement for
ART, if there is a placebo involved, that blinding is nearly impossible because
of the follicular response. In
monitoring a cycle with the placebo, if there is no follicle response, it is
very clear on ultrasound and so that is an issue that I think is important as
we look forward to the subsequent discussions that we will be having.
There
are other questions. Yes?
DR.
EMERSON: On one of your slides, you
remarked about the superiority of being--whether it was necessary or not and
you included in there superiority against a placebo would potentially
have--would not be a necessity and due to convenience of what? I guess I am not understanding where you would not require superiority against a
placebo.
DR.
KEEFE: The emphasis in that slide was
that superiority does not need to be demonstrated to show superiority--if the
outcome is pregnancy, it is not necessary because there may be superiority in
other outcome variables such as convenience, pain, and so on. So the emphasis there was on the importance
of taking a broad view of the outcomes, not just pregnancy rate, or not just
ovulation, but also user-friendliness, the intrusion on the person's life.
So
the placebo issue, as I mentioned, I think there is a limited role for placebo
treatment in most IVF studies at this point, although I could imagine for
ovulation induction, certain treatments are unexplained in fertility, there
could be a limited role. So there, the
importance of that slide, or the point was that it isn't just pregnancy outcome
but also convenience and pain would also be important outcomes.
DR.
EMERSON: Another question. When you were listing your potential for
improved biological surrogate markers, it wasn't immediately clear to me
whether this aneuploidy, as a predictive value, could just be used to improve
the efficiency of the whole procedure rather than be a surrogate endpoint, as
itself. I mean, is there enough
evidence, really, to suggest that it, as a surrogate, would be indicating
whether the treatments were successful or is that just a means whereby we can
improve the whole IVF process and it is not really indicating the drug
response.
DR.
KEEFE: Those are good questions. We don't have enough evidence at all. I mean, there are only limited studies from
Gianaroli's group, from Santimine's group, that are suggesting its potential
value. I mean, we really need to do more
studies, larger studies.
But
that really was looking to the future.
As we look forward, I think we will see new technologies that allow us
to look at all of the chromosomes. Once
you have a helpful predictor of outcome, that, I believe, will become the most
useful marker of the outcome.
So,
if you have something that is predicting with high fidelity the implantation
rate of a given embryo, then that will become a useful marker of how you are
doing with that, and one of those factors will be the treatment. It is true, though, that, as even with IVF,
itself, probably the most important thing is not the drugs that are used or the
way they are used. It is the
patient. There is a huge
patient-specific or patient-dependent parameter that is difficult to get our
minds around and to measure.
I
suspect that a lot of that will be aneuploidy.
Then, once you have that nailed down, then you will be able to look at
the potential effects of drugs or stimulation regimens on that. Until we do that, you know, we use things
like age or FSH. These are explaining
about 10 percent of the outcome in logistic regression equations. They are almost noise.
They
are the best we have but we don't have a good understanding of the factors that
drive the outcome. My bet, and, again,
this is pure speculation at this point, that a lot of this will be aneuploidy. It will be the propensity towards
aneuploidy. PDG is just the tip of the
iceberg. I suspect that SKY or
comparative hybridization will allow us to really get the handle on that and
then, once you have that level of determinism, then you can look realistically
at potential impacts of drug-stimulation regimens on the outcome meaningfully.
Of
course, as it is now, you can just randomize everything and it will all fall
out. But you have a lot of noise in the
system and it makes it very hard to do studies in a practical way that shows
anything.
DR.
GIUDICE: Dr. Macones, Dr. Rice and then
Dr. Stanford.
DR.
MACONES: Dr. Keefe, you had a couple of
slides about ovarian hyperstimulation. I
was wondering if you could give me some information about how predictable it is
based on estradiol levels and, I believe, either follicle size or number.
DR.
KEEFE: So ovarian hyperstimulation
syndrome is a really, really adverse outcome that is very hard to predict. So, for example, there is a review by Mary
Lau for Infertility and Sterility about six or seven years ago in which he sort
of put it all together. Most of us use
the cutoff that he used which is 3500 picograms per ml of estradiol at the peak
to block the trigger, to stop us from triggering. But that gives a predicted risk of
hyperstimulation of about 5 percent.
So
we are acting very conservatively because of the risk, the low risk, of a
severe outcome. Just as PGD,
preimplantation genetic diagnosis, should enable us to better understand the
things that are driving outcome, the increased understanding of the
pathophysiology of ovarian hyperstimulation, I suspect, also, will allow us to
get around that outcome, adverse outcome--growing evidence that
vasculoendothelial growth factor is one of the drivers of this vascular
permeability may allow us to use that as a maker.
But,
in the meantime, most of us use a very conservative cutoff to avoid the risk of
the severe sequelae of hyperstimulation even though it is a quite rare outcome.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: Dr. Keefe, you briefly mentioned
the SART database which I guess now is sort of the SART-CDC database. I am wondering, your comments on that
database and how we can effectively use it as to help us address some of the
outcomes or address any differences in product.
I
was struck by the fact that I sat on a thesis committee for one of our
colleagues who was getting his Masters about 1998, 1999 and he used that
database as the basis for his thesis and really did show that African-American
women who participate in ART procedures, even when you control for Day 3 FSH or
age, had lower pregnancy rates and this was never really brought out in a real
public manner.
So
I am just wondering if we could better utilize that database to help us address
some of these questions.
DR.
KEEFE: That is a really good
question. I think the SART database is a
beginning. We have begun to answer some
interesting questions. There is a
tension within the community about the SART database. On the one hand, some view it as sort of a
threat, that they are being exposed, the real size of their pregnancy rates is
being revealed before everyone else.
They
will often argue that, gee, the patients don't really want to see all these
numbers. It is very complex. On the other hand, there is a huge potential. I think what we should use--get a lot more
information from that on the patient side.
There has been an argument that there is too much on there already. Patients go to it and they get just
overwhelmed by so much information in front of them.
I
think that what we could do is we could use, like, hyperlinks. If you want to know more about the inclusion
and exclusion criteria about a specific clinic, that should be put in
there. One of the problems is there is a
lot of variability among clinics and who actually is going through. That should be posted. It should be "buyer beware." In other words, all information available for
those who want it and then you could have hyperlinks which you click and that
brings you into inclusion and exclusion criteria for a given clinic.
If
the inclusion and exclusion criteria are not published there, the patient
should have full rights to go through it, whatever particular situation they
have.
On
the research side, I agree with you.
There are a lot of interesting questions that could be asked. One of the concerns that I have had is I am
not sure how available that database is to those who have questions. I have talked to a couple of colleagues who
have approached them and discussed projects, and they kind of go into a queue.
I
am actually just newly elected to the Registry Committee for SART so that will
be one of the issues I will be bringing up is accessibility. I think that the data should be
transparent. It should be
accessible. It should be available. People that have interesting questions like
the one you are raising should have a shot at it. Only then, you know, we will be able to
really take advantage of it.
As
we used to say, they have all the answers but we have all the questions.
DR.
GIUDICE: Dr. Stanford?
DR.
STANFORD: Dr. Keefe, I wonder if you
could comment generally on the issue that these ART protocols involve multiple
complex regimens, as you mentioned, multiple drugs with multiple different
scheduling of them. When it comes to
investigating and trying to establish the efficacy of a new drug, you have all
these other variables, all these other drugs, drugs that you are using with it
that may or may not have been approved for that protocol or that indication as
well as the patient factors.
This
may be something that we discuss later as well and I would be interested in FDA
staff input, but I am just interested in your--what perspective you would have
on that if you are trying to nail down, is this drug effective, when you have
all these other variables.
DR.
KEEFE: That is a great point. I think it was Alfred North Whitehead that
said that science is the art of the answerable.
This is a lot of art and not too much answerable. I agree with you. It is such a complex moving target. But that is why, in a blinding, at least with
regard to drugs, it would be very helpful because if all that goes out in the
wash, then it is less important. But if
those other things are being tweaked in response to the biases on the part of
the investigators about the control versus the new drug, you can imagine a lot
of mess that would create.
But
I think if you can let it all fall out in the wash, you could still find useful
information out of it. It is just the
numbers are just enormous when you have so much noise, so much error, in the
equation.
You
are right. It is a very complex
experiment we are doing.
DR.
GIUDICE: Dr. Toner?
DR.
TONER: Just a point of information
regarding the question of the SART database.
It is, at this point, a joint effort with the CDC and, to use those
data, you need permission from the CDC.
That is doable. I have done it on
a couple of occasions.
But
probably more pertinent to the gonadotropin question is the fact that, at this
time, the database simply collects how many units of FSH were used in that
cycle. So you have nothing about the
brand, nothing about how much LH was or wasn't part of it, or any concomitant
medications that certainly would influence outcome.
So
I doubt that that database, in its current form, will be of much use for this
topic.
DR.
GIUDICE: Dr. Crockett?
DR.
CROCKETT: Yes. I am particularly interested in the research
that you presented about the abnormal spindle formation and the aneuploidy
rates. It struck me, as I was listening
to your talk, when we talk about using control groups and placebos and
double-blinded studies, there is very little discussion about comparing these
outcomes to what are normal, healthy, fertile, maximum fecundability is as
humans.
Particularly
regarding the aneuploidy and the miscarriage rate, could you just discuss the
ramifications of using our healthy human population as a comparison?
DR.
KEEFE: That is a good question. Battaglia's research on spindles actually
used normal volunteers. He had an NIH
grant and normal volunteers were monitored and then their eggs were retrieved
under the spontaneous surge, hence the low numbers in the study It is hard to get a single egg.
That
is one of the few studies. Others have
used natural populations, natural cycling populations, to look at aneuploidy
rates. Placheau has found 25 percent of
eggs are aneuploid in normal situations when they are aspirated. Also, Pat Hunt has found similar rates with
using karyotypes.
There
are no head-to-head comparisons, but if you look at assisted reproductive
technology cycles, the rates go much higher, particularly as you get into women
who are in their late 30s and early 40s.
Using comparative genomic hybridization, and SKY, the group in St.
Barnabas is finding the majority of eggs in women with infertility have
aneuploidy, so more than 50 percent, one study up to 70 percent, of the eggs
could be identified.
There
is also a false-positive rate with that.
Hypoploidy is actually a missing chromosome that washed off the
slide. But, still, there is a very, very
high rate of aneuploidy in humans. One
wonders why any of us are walking around talking like this because we are all
survivors of this massive struggle for existence.
Some
have argued that, in fact, the human has evolved as a mono-ovulator with
subfecundity because it is such as social species and there is such an
important role for socialization. You
can see the same pattern of reproduction in other long-lived social species
like whales and elephants and primates.
So
there are two parts to it. One is that
we are mono-ovulators and we sort of get programmed in a very limited fecundability
and, on top of that, we live long. So
you have sort of two hits. You have a
defective egg, or a low number of eggs that are likely to be defective at any
given time plus a long period of time where wear and tear sort of damages what
minimal reserve we started with.
DR.
CROCKETT: I guess what I am asking is
when we look at these reproductive technologies, is our goal to overcome that
or to match it.
DR.
KEEFE: That is a good question. A lot of people argue, well, gee,
disease--aging is not a disease. Aging
is a natural process. But I think that
draws a distinction that doesn't exist in the rest of medicine. For example, I have a bad hip. No one has ever questioned that, as a
49-year-old walking into an orthopedic surgeon, that I shouldn't expect to have
a bad hip when I work out every day and so on.
Yet, no one questions whether that should be covered by insurance.
I
work in a state where there is an IVF mandate but almost every day I have to
battle with the insurers that a 38-year-old, 39-year-old, 40-year-old going
through infertility with a high FSH is going through a natural process.
Nature
has never been thought to be benign. I
mean, nature causes diseases. This is
sort of the equivalent of a balanced polymorphism. It is like sickle cell in certain populations
that lived in environments where that was advantageous. I think reproductive failure in women was
advantageous at a certain time in history.
Currently, it is a disease. It
gets in the way of women who make great sacrifices in their lives to do things
for other people and then, at their stage of life, are now prepared to complete
a family and nobody told them that, by the way, this is a natural process, you
should have done this instead of go to law school or med school.
So
this is a disease like any other disease.
You know, sure; it is a natural process but it is a natural process
which wreaks havoc. It is a misadventure
for our current society. It is the other
side of the contraceptive evolution and one that we should, I think, attack
with equal vigor.
DR.
GIUDICE: Dr. Brzyski?
DR.
BRZYSKI: I would like to ask, thinking
about the different types of patients, you mentioned a little bit about the
different types of patients that are treated with fertility medications. Do you think that that should be taken into
account in terms of the safety and efficacy outcome variables that we look at?
For
instance, a specific example I was thinking about is women with polycystic
ovaries have a high miscarriage rate. So
you could envision an intervention that might not be very efficacious in terms
of ovulation rate but may significantly reduce miscarriage rate whereas that
might not be an outcome that might be of relevance to someone, say, with
hypogonadotropic hypogonadism.
So
I just wanted your opinion about whether the outcomes that you look at should
vary from patient population to patient population or should it be standardized
across the whole drug group?
DR.
KEEFE: I agree with you there. There are important diagnostic distinctions
to be made. The one you described is
probably one of the most important as well as the male-factor patients
that--there is a big difference between hyper-responders, particularly those
with a polycystic-ovary-type dynamic in unexplained infertility patients or
patients with tubal disease and what is going on inside their ovaries. So that is a useful distinction.
I
think less useful distinctions are minimal endometriosis, mild male factor,
unexplained infertility. Those
diagnostic categories are much less meaningful.
So it might be useful to set up a series--sort of revise our diagnostic
categories as a field. We have been very
hazy in our thinking.
You
wouldn't see this with cancer or heart disease.
You have different stages. You
have very clear-cut diagnostic categories.
We tend to use these textbooks that we all read back in, you know, the
first year of medical school about the causes of infertility. Most of them are not really that useful.
I
think the one you mentioned is, polycystic ovary syndrome, severe male
factor. Those really mean
something. Complete tubal disease, tubal
obstruction, those are meaningful. And
then the rest, sort of the rest, of the diagnoses have much less meaning in
terms of outcome. They are not anchored
as much in--they are not as valid.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I think Dr. Toner made a good
point when he captured really the essence of what I was getting to that we
probably don't ask all the right questions of the SART database in order to do
the right research.
I
want to ask you your opinion on this.
You are in a mandated state and I know the insurance carrier there
requires that you get a certain amount of information on a patient before
starting her on an IVF cycle. Are you
finding a level of consistency by these insurance carriers requesting similar
types of information when you are in mandated state versus when we are in a
non-mandated state where people don't have maybe the same criteria for starting
a patient on IVF? Are you seeing any inconsistency?
DR.
KEEFE: There is a lot of
inconsistency. It is a huge
problem. We spend a lot of time haggling
over whether somebody, indeed, merits IVF treatment or not. We have convened a group, sort of working
group, of the different IVF programs to come up with a consistent series of
inclusion and exclusion criteria that we can all agree on.
The
problem there is that, even within our group, there is a disagreement,
particularly as you get into the low-prognosis patients. Are those the ones that should first be
treated because they have the least probability of conception on their
own? Or should they be the last that are
treated? So there is a lot of
inconsistency.
DR.
GIUDICE: Are there any other questions
from the committee? Yes; Dr. Shames?
DR.
SHAMES: I just wanted to make a comment
sort of to prod the committee, and this is early in the process, to start
thinking a little about the problems that we have as regulators. Dr. Keefe brought up one point which makes me
want to use as an example. Is the point
of doing a noninferiority trial, say, for a drug in a situation where the
procedure or drug would have an advantage of convenience or discomfort, et
cetera, et cetera, which we all certainly understand.
The
problem for us, of course, is how to measure the convenience and discomfort,
how to incorporate it actually into a statistical analysis plan, et cetera, et
cetera, on top of a noninferiority trial.
I am not asking for details. I am
just saying ultimately we want to sort of standardize things which we will
believe will help move this process faster.
We
need to standardize to be sort of fair so when we discuss things like this, any
of these issues, we should have in our minds how we actually are going to
translate this into real trial designs and analysis plans, things like that. That is my comment.
DR.
GIUDICE: That is an important
comment. We will get to Dr. Lewis in
just one moment. Along the same lines,
in addition to outcomes, there is also the issue of time for getting to a particular
outcome which, in infertility therapy, some women respond very quickly to
gonadotropin stimulation. Others take a
very long time. Those are measurable
outcomes.
On
the patient side, there is also the issue of getting to the clinic or getting
to the office, time away from work. So,
somehow, I think we also probably should keep that in mind.
Dr.
Lewis?
DR.
LEWIS: I agree with the points you just
made. the other thing I wanted to just
mention briefly about the SART database, while it is useful to look at, it is
all retrospective data and it is not controlled. It is particularly biased by the specific
clinic and what their criteria or prescribing habits might be as well as their
selection criteria which vary hugely.
So
I don't think that it can substitute for a well-designed, prospective trial.
DR.
GIUDICE: Thank you for your
comments. Are there any additional
questions from the committee? Yes?
DR.
EMERSON: I would just like to visit the
question of the gold standard that you listed which was the number of live
births per cycle of therapy. I guess,
you know, there are some worse in terms of needing larger sample sizes and you
could be looking at the time until you had successful live birth, so measuring
the number of cycles needed until someone got that. These have some problems as well.
I
guess what I am worried about most in all of these is the ability of bias to
creep in for one treatment versus the other in terms of the clinicians response
to cancelled cycles or to not trying further cycles with a patient. Could you comment on that?
DR.
KEEFE: That is a huge factor. In clinical practice, it is an enormous
factor, enormous, because now, all of a sudden, any patient can go to the web
and pull down the statistics which are a reflection, largely, I think, today,
with standardized media, with standardized training for most of the
embryologists, with standardized protocols for clinical, a lot of the
variability is arising from the patient mix.
There
is a growing practice of explicit or implicit exclusion of the sickest patients
which I think is immoral. On the other
hand, some would argue that physicians are increasingly charged with allocating
scarce resources. But those are tricky
and difficult to balance. I don't think,
from the standpoint of the traditional mission of the physician, it was our
major commitment.
There
is a growing practice of what I call the Lake Wobegon effect where everybody is
above average in my practice so we are above average. That is a problem.
There
was an article in The New York Times Magazine about healthcare about two or
three months ago. The only other area of
medicine that has a registry that is so visible as that for in vitro
fertilization is cardiovascular surgery.
That is exactly what is going on with cardiovascular surgery.
There
was an article by a cardiologist in New York City about how difficult it is to
get a bypass on a patient who really needs it in New York City today because
the "best" surgeons don't want to touch the poor guy. So that is a problem for all of us in
medicine.
I
am the first one to believe in consumerism.
There is sort of an avalanche of consumerism. That is great. But my response to that wouldn't be to stop
the data from coming but to increase the flow.
So, for the registry, I think we would mandate inclusion and exclusion
criteria be attached through a hyperlink to those clinic-specific SART rates so
that, if a patient goes there and they get cancelled, and they go on the web
and say, whoa; wait a minute. This isn't
on your exclusion criteria for who can to through the next cycle, then they
have a right to go through again.
I
think the AMA and ACOG, ASRM, all have, in our ethical sort of statements, the
right of every physician to not treat a given patient as long as it is
standardized and mutually agreed upon and it is explicit.
So
I think the data should be there so that couples can decide, up front, or women
can decide up front, whether they want to go to this center that is extremely
exclusionary versus another which isn't and so they can go the whole ride if
they need with a given center. That is
the only way I think we can deal with it.
We
can't have less data, less information.
We need more information. The
argument that patients don't want to see all this. They don't have to. They can have a hyperlink.
DR.
EMERSON: I guess one of the points I was
at was a more technical one. It is the
concept that, for instance, there can be differential actions by treatment arm
according to deciding to cancel a particular cycle and not go forward with the
stimulation or whatever.
DR.
KEEFE: That is a good point. In terms of the outcome, if you were
randomized, again, that should fall out in the wash. You might want to balance both arms of the
treatment within a given center because they tend to be center-specific
criteria. You also might want to make
explicit up-front the clinic's criteria before they start to enroll patients.
DR.
EMERSON: Although, it won't pick that up
if you are using as your denominator the number of cycles. There is a lot of room to play with number of
cycles that you go through, both in terms of sort of the--I always look at
things from the "intent-to-cheat" perspective and say, how can people
cheat on a particular thing to make something look good.
If
you set out to do it, what would you do?
And I say, well, gee, if I want my treatment to look good, what I will
do is, as soon as I hit a patient that looks pretty hopeless from, for
instance, aneuploidy or whatever, that they do that, if they are on the arm
that I don't like, I will just keep on sending them through cycles and, if they
are on the arm that I like, they won't.
Similarly--
DR.
KEEFE: Can't you just deal with that by,
once they get included in the study, then they get randomized after inclusion?
DR.
EMERSON: The idea is--the problem is
using the number of cycles as a denominator whereas, if you just used time, and
said, we are going to measure everyone as the time until you achieved a live
birth, and people who you cancelled permanently after that, and you just
refused to do more cycles on them, well that is at infinity.
DR.
KEEFE: The other way to do that is just
to include first cycles in the study which I think, in terms of the way IVF
works, is probably not a bad idea because there is that huge source of
confounder which is whether they get to go through it again, according to the
policies.
But
there is also a difference, not so much first and second, but first and third,
first and fourth, in terms of the mix of the patients. They are different people.
DR.
GIUDICE: Yes; Dr. Stanford?
DR.
STANFORD: I think there is another
potential concern. You talk about a gold
standard being live births per cycle initiated.
But then there may be--ART, obviously, there are certain categories that
you mentioned where it may be the only way for a pregnancy, azoospermia, et
cetera. But there are other categories
where it is becoming more broadly used and there is debate about should you go
with controlled ovarian hyperstimulation versus ART or metformin for certain categories of PCO and all that
kind of stuff.
I
don't think you can make a fair comparison on the per-cycle pregnancy
basis. I think, in those cases, you have
to come up with some kind of measure that is an overall--given a course of
treatment, whatever that is, which may take longer on a non-ART side or a
non--whether or not you call controlled ovarian hyperstimulation part of ART,
but on a non-IVF side, you have account for another course of treatment that
may be cheaper, may have less risk in some ways but may take longer.
Could
you comment on how you could compare those in a randomized way?
DR.
KEEFE: One study design that I think has
been underutilized is a crossover study.
Because the majority of our patients are not going to get pregnant in
the first cycle, and the first and second cycles are not that different in
terms of the patient mix, one way to do it is to do a crossover where each
patient is their own control.
Of
course, there are problems with that, obviously, but one of the huge advantages
is that, as I mentioned, and I think everybody would agree in this room who
takes care of these patients, that the biggest confounder is the patient,
herself, her eggs, her aneuploidy, whatever is going on inside there.
There
are fertile people and there are infertile people. So if you randomize the patient up front to
Treatment A in the first cycle, or B, and then flip it around on the other
side, then I think that is a very sensitive way to tease apart some of these.
Of
course, it gets around the issue of not allowing them to go through because
they are stuck. I mean, they have got to
do at least two cycles if they don't get pregnant the first. If you get pregnant with the first, obviously
that creates a problem; they don't get to the second, and how you treat those.
But,
given the problems with the other study methods, you can imagine a way that
that could be a very powerful way to be able to put together all these very
complex factors that are influencing the outcome.
DR.
GIUDICE: Yes?
DR.
TULMAN: I have a question about the gold
standard as well. You mentioned the gold
standard being a live birth. Could you
comment on adding the adjective of "healthy" live birth to that?
DR.
KEEFE: Okay. The issue of anomalies with assisted
reproduction is really important. I put
them in safety concerns. I think I would
still leave them as a distinction. I
have, in my practice, my office, last week a woman who came--she is a
physician, actually, an OB-GYN, who brought her twins from IVF. Both have cerebral palsy and she was coming
back for some more.
I
said, "How can you do this? You
must have a lot of stuff on your plate."
She said, "They are my babies.
They are my kids. People say they
are abnormal. I love them. They are beautiful." And she wants more.
Now,
that is not everybody. I think there is
enormous value for somebody who has never had children to have a baby. Not everybody receives their cerebral palsy
the way she did, but I would still put down the birth of a child as a
benefit. I would put down the others as
side effects, as potential complications, and try to eliminate them or reduce
them.
We
don't know all the mechanisms. We know
that the biggest component is the multiple gestation. That is the biggest driver. But there may be other abnormalities as well
that arise from imprinting abnormalities, problems with polarity. This monozygotic twin thing is huge. It is not just the zona hardening. There is a lot going on there. They tend, overall, to be so rare that you
have to use a study like the Australian with 10,000 patients following in a
registry over huge periods of time before you find them.
So
I would hold fast that we still are looking at babies. I think the definition of a healthy baby--it
is important to put that in as a complication, but, for the vast majority of
patients, and I think a number of studies have looked at that, they are very
happy with that.
DR.
TULMAN: Just a follow up, if I may. Is there any move within the FDA or CDC to
establish some sort of registry within the United States of the children who
were born as a result of the reproductive technologies to follow them for not
only the problems that may be apparent at birth or soon thereafter but in terms
of a longer range, in terms of other health problems?
DR.
GIUDICE: Dr. Brzyski?
DR.
BRZYSKI: I will comment on that. I am the President of the Society for ART and
so work very closely with the CDC on the registry. That discussion has been, at several levels. CDC has certainly recognized in their
publications the issues of, say, adverse outcomes and the problems that are
associated with trying to identify adverse outcomes such as birth defects,
congenital anomalies. That has been
discussed in some of their publications.
From
the CDC's standpoint, well, let me just say that from the consumer standpoint,
that is certainly an issue that I have discussed with patient advocacy
groups. There are sort of two opinions
about that. There is a group that
believes it is extremely important to collect this information and another
cohort that is concerned about privacy issues and stigmatizing the children
born from ART technologies by sort of identifying them or categorizing them in
that way.
So
it is definitely an issue that needs to be discussed more, both from sort of a
philosophical standpoint and from a practical standpoint in terms of the cost
of generating such an effort.
DR.
GIUDICE: I am wondering, Bob, if you
could comment on the European experience of keeping long-term outcomes compared
to in the United States because that may address some of the question.
DR.
BRZYSKI: I don't have direct experience
with this, but there have been discussions at the SART Executive Council level
of the experience in Belgium with ICSI outcomes. My understanding is that it has been an
extremely expensive and time-consuming effort to collect those data on ICSI
cycles, even in a relatively homogenous environment of a small country like
Belgium. Well, I guess it is not really
that small because there has been some--those patients have probably traveled
from various places.
But
it has been a noteworthy effort to collect those data but at a significant
price.
DR.
KEEFE: I think the European experience
has been an excellent one in terms of generating very useful data for the rest
of us to use. We started on a small
project that was funded by the Rhode Island Foundation to look at outcomes of
IVF babies born in Rhode Island because we are sort of a Mayo Clinic, the only
IVF program for this million-and-a-half people.
So
we had a lot of potential there. About
three months into the study, we got a letter from a very irate former patient
who had a beautiful baby from IVF but was, herself, a lawyer for the American
Civil Liberties Union. She was
absolutely livid that this letter arrived at her house, which had been approved
by our IRB, that her mother-in-law had inadvertently spotted and mistakenly
opened because they have similar names, threatening to sue us for
revealing--the problem is we are in the frontier here and we still have a lot
of sort of notions of individuality and freedom and so on that it makes it a
little harder.
They
shut down our study. That one example
was enough to scare the IRB and the hospital to shut it down and say, "No
more." So it is tricky, in America,
where there is so much concern of privacy and individuals' rights. I think
it is valuable information, though.
DR.
GIUDICE: I think it is also important to
point out that there is no organized effort for keeping track of babies born
from gonadotropin stimulation cycles as opposed to ART.
Dr.
Layman, did you have a comment?
DR.
LAYMAN: Yes; I had a comment. I think it is important to try to collect the
data. I know it is difficult, especially
with HIPAA. We know that, in general,
congenital anomalies are in 2 to 4 percent of all couples and that IVF
increases slightly sex-chromosome abnormalities and some other aneuploidies,
but I think, as far as the issue of the imprinting disorders, if we don't start
getting a database, we will never know for sure whether this is a real issue
and whether it is due to IVF or ICSI or both, or whatever.
So
I think it is important to address this, at least future SART collection data.
DR.
GIUDICE: Thank you. Are there any further questions? Yes; Dr. Emmi?
DR.
EMMI: I just wanted to ask a question,
or if you would just comment. You had
said that different infertility diagnoses are not quite so important. Would you just comment about different
institutions using different policies for diagnosing conditions in in vitro,
even, as far as unexplained or male factor and how that might affect the
studies.
DR.
KEEFE: The rigor of the diagnostic
categories used for IVF is very low. So
you will see frequently minimal endometriosis scattered throughout. That is probably a much better marker of
whether the patient had a laparoscopy as part of her workup than it is about
her disease or her prognosis.
Similarly,
with unexplained, it depends on how extensively you look for other
factors. So, as I mentioned, I think the
most important diagnoses are severe male factor, complete tubal occlusion and
polycystic ovary syndrome with insulin resistance. These are the sort of diagnostic categories
which I believe, in the end, will hold their own, at the end of the day, will
still be standing after critical review.
We,
as a field, I think, should revamp our diagnostic categories. I think we should also have a dual classification for infertility, differing
staging for the level of infertility rather than--age is a very, very poor
predictor of anything. Chronologic age
is not a good predictor of biological age.
Just
look at anybody's clinic when you look at patients who had an anastomosis
failed or who had a tubal ligation and they go through IVF. They have a very good prognosis independent
of age. If you look at the registry,
these studies that use sperm donation clinics to look at the effects of age on
fertility, 45-year-old women still have sort of a 30 percent pregnancy rate, 25
percent pregnancy rate.
The
fertility rate doesn't drop that precipitously in the general population as it
does in the IVF placebo because the IVF population is that subset of the
general population that really has it bad.
I mean, clearly, age affects fertility but the relative impact of age on
a given--or senescence, I should say, or aging rather than chronologic age, is
highly variable. That is the key factor.
We
should develop way more rigorous work. I
know Jim Toner's very important work on FSH is a beginning, but there is a need
for increasingly precise measures of a specific patient's individual senescence
level or aging factor.
DR.
GIUDICE: Dr. Shames?
DR.
SHAMES: I just want to make a comment
that the FDA can and does ask sponsors, as part of the approval process, to do
some pregnancy registries. However, this
is voluntary and we cannot compel them to do it.
The
other problem, of course, is, in this area, we are dealing with multiple drugs
and procedures, for that matter, so it is difficult, of course, to tease out
the cause of some particular abnormality.
But we can, in the process, ask sponsors to do that.
DR.
GIUDICE: Thank you. Dr. Rice?
DR.
RICE: Why does the FDA have limited
authority in requiring that part of the registration of a drug, approval of a
drug, not lead to a pregnancy registry?
DR.
SHAMES: That is sort of a legal
question. There are certain things that
we can and cannot do by regulation. I
mean, I would have to go back and ask that, why we do not have regulatory authority. It would have to be created as a regulation
or a rule which has not yet been done.
Whether we would even have the right to do that, is a whole legal issue
which I cannot speak to. But we can
certainly investigate that situation.
DR.
GIUDICE: Thank you. Any further questions? If not, I would like to thank Dr. Keefe again
and the committee members. Let's take a
break and return at 10:15. Thank you.
[Break.]
DR.
GIUDICE: For the second half of this
morning's session, I would like to introduce Dr. James Toner who is Director of
the Atlanta Center for Reproductive Medicine in Woodstock, Georgia. He will tell us about Gonadotropins in ART.
Gonadotropins in ART
DR.
TONER: Thank you, Dr. Giudice and thanks
for the invitation to attend this panel.
[Slide.]
I
hope it leads to more streamlined ways for us to understand what kind of
efficacy endpoints are expected of us in evaluating new drugs. I was asked to talk about a few different
components of this and we will start, really, by talking about in vitro in this
country, kind of how we have come in the first twenty years of use and then tie
in the approach we have taken on the clinical basis to achieve these improved
outcomes, especially as regards to gonadotropin usage patterns.
[Slide.]
As
most of you in the room know, IVF has been successful for almost twenty-five
years now, the first birth being in England and a birth shortly thereafter in
the United States in 1981 in Norfolk, Virginia.
[Slide.]
The
story within this country, ever since that beginning, has really been one of
improving success rates, reduction of multiple pregnancy rates, introduction of
new therapies. It also, I think, is a
story of the advantage, in a way, of the American system, the flexibility we
have had as clinicians in this country to incorporate new treatments. To adjust the number of embryos going back
according to age and other things has led to higher success rates in this
country than certainly in Europe.
[Slide.]
The
simpler treatments include things such as the ability to remove eggs
transvaginally. It used to always
require a laparoscopy and a transvaginal approach under a light sedation is
certainly an improvement and, also, the essential abandonment of replacement of
embryos into the tubes, also through laparoscopy.
In
the early days, most of us also asked the women to come daily or nearly daily
through the whole stimulation process to evaluate their response. That is not necessary anymore. Also, in the beginning, essentially all the
medications that we needed to give were given by the intramuscular route. Now, with the possible exception of
progesterone, almost none of them are.
So
those have all been improvements in the treatment simplicity.
[Slide.]
There
has also been introduction of new therapies.
Initially, it was designed as a process to deal with the problem of
blocked tubes but it has since turned out to be quite effective when sperm
numbers or quality are quite diminished, when eggs, themselves, are diminished
by really substitution therapy, using donor eggs. When the uterus has an intractable problem, a
carrier can be brought into the mix and that is a very successful strategy.
Initially,
surplus embryos were a problem but cryopreservation is now quite an effective
use of those extra embryos. As Dr. Keefe
alluded to, genetic problems, either that come with age or might have been
there all along, in particular, couples can be screened for with
preimplantation genetic diagnosis. None
of these things were there at the start.
[Slide.]
Now,
the innovations over time have really proved to be a fairly steady
progression. Cryopreservation in the
early 80s, donor egg in the mid-80s and then the attempts at putting the
embryos or eggs back into the tube, themselves, where they normally would have
been by GIFT and ZIFT were widely practiced for a time but, as you can see, are
not common anymore. Co-culturing of
embryos, dissecting away the zona to some extent in hopes of permitting sperm
easier entry or simply putting the sperm under the zona were early efforts to
achieve fertilization when sperm were a problem, again, approaches that have
since vanished for all intents and purposes.
Those
have been replaced by ICSI, the direct injection of sperm into eggs. Hatching was introduced in the mid 1990s,
preimplantation genetic diagnosis, again in the mid-90s. In efforts to get around problems of
diminished egg quality, attempts have been made to either transfer cytoplasm
from healthy eggs into aging eggs or to move the nucleus across to a healthy
egg.
So,
in the field, there really have been steady innovations. The three that I have put Xs next to are no
longer permitted to be done in this country until appropriate, I guess, safety
studies have been performed.
[Slide.]
Now,
the focus of this meeting really is gonadotropins. I wanted to illustrate, first, a time line
that illustrates when these gonadotropins and the things that affect
gonadotropins have been introduced.
As
many of you know, the urinary products came first. hMG was available even years before in vitro
came into existence and was really the only gonadotropin available for use in
the earliest years of IVF. In the
mid-80s, a more purified version, still urinary but with a dominance of FSH,
was released.
In
the late 80s, Lupron, which is a GnRH agonist was released and widely
incorporated into practice shortly thereafter.
More and more purified forms of FSH were also developed in the mid-90s,
again urinary at first and then recombinant shortly thereafter.
The
most recent development has been the development of GnRH antagonists. It took us actually years, on a clinical
level, to figure out how best to use the GnRH agonist and we are still, I
think, on a learning curve of the same sort when it comes to understanding how
best to use the antagonists. But they
have become adopted into practice pretty widely.
[Slide.]
Now,
kind of with that as a background, let me describe to you what I think has been
the general trend of use of these medications over time for the purposes of in
vitro. The very earliest success with in
vitro was, in fact, in natural cycles.
That is how the cycles went in England, initially. But the Jones, who tried to get it going in
the States, had a very poor experience with that and, instead, moved quickly to
Pergonal, an hMG product and used, as you can see, at very low dosages, 2 amps
a day, typically.
It
wasn't long thereafter that the advantage of even stronger stimulation was
recognized because, other things being equal, within a certain range of hMG
use, the more you give, the more eggs you can allow to grow or cause to
grow. So 2-amp-a-day protocols became
very uncommon and more typical dosages were 4 or even 6 amps of medication per
day.
They
were often blended with FSH in those years although, in the early years, there
was typically always some use of hMG which contains not only the FSH but the LH
product, the LH hormone, I should say.
When
Lupron became available, it was first employed as a suppressive drug starting
in the preceding luteal phase and seemed to very clearly allow more eggs to
grow, at least more synchronous growth of eggs, so that, in most patients,
simply by adding this sort of a pre-treatment, you were apt to get more
high-quality eggs than if you went without such a product, even with the same
dose of stimulation.
A
few years later, it was discovered that you could take advantage of the fact
that the agonists first cause a flare of gonadotropins and that flare was then
used to augment the stimulation and was begun typically at the early part of a
menstrual cycle along with the other stimulatory drugs to cause an even
stronger response.
For
a time, there was a lot of advocacy of the use of pure FSH rather than the
hMG-style product through the mid-1990s but many clinicians have since gone
back to a blended protocol where you are taking at least some LH in many
cycles.
Birth-control
pills were introduced in the mid- to late 90s as a way to control the cycle
start time, especially in a case where you are not going to use a suppression protocol
of this sort. Without PCO pretreatment, you really had very little
control of when the cycle would actually start and the pills have been useful
in that arena.
Then
the most recent change has been the introduction of the antagonists into
clinical practice which have largely been used simply late in the stimulation
to prevent the premature LH surge.
[Slide.]
Now,
with those medications being used in the way that they have been used, there
have been certain trends over time.
Clinics; we have, obviously, many more treatment clinics in the country
now than we did in the early years which, in turn, has led to many more cycles
of treatment, now over 100,000 such on an annual basis and many more
deliveries.
[Slide.]
But
really, more importantly, is the fact that the success rate per treatment cycle
has steadily climbed no matter which major kind of treatment you want to
consider. In vitro is here in the
middle, in green. In the early days, 15
percent of cycles produced pregnancy per transfer. Now, 40 percent of them do.
The
orange at the time is donor-egg success rates which have doubled from 25 to 50
percent per try. And freezing, which
didn't work well at the beginning, in yellow here, now adds about 20 percent or
25 percent advantage to the cycle if you have had extras and can freeze them.
The
other two little things in here are the ZIFT and GIFT which were, at first,
more successful than standard IVF, at least on a national basis, but, as the
IVF success rate rose, that advantage has disappeared and, in a sense, killed
off that therapy altogether. This shows
the proportion of cycles over time that were GIFT and were ZIFT. You can see these things peaked in the late
80s but, as the success rate between them and standard IVF has increased, their
usefulness has gone down to the point where only 2 or 3 percent of cycles
are done by that method.
[Slide.]
One
real success story has been--my computer has frozen. I will tell you what that slide said. I don't know why it wasn't working. In the early days of in vitro, when sperm
were not normal, simply putting sperm in the eggs, sperm in the same dish as
the eggs, produced some pregnancies but nowhere near the normal rate.
The
short story is that this direct injection of individual sperm into eggs, ICSI,
has taken a very low poor outcome that was happening before the technique was
introduced and erased that problem altogether to the point where now, as long
as there is sort of one living sperm for every living egg, it is as if there is
no male-factor problem at all in terms of pregnancy rates.
[Slide.]
This
shows the incidence of multiple pregnancies over the years as well which have
been highest in donor egg and lowest in frozen embryos and mid-range, about
35 percent, in standard IVF which is higher than we would like but I did
want to emphasize the problem of triplets and quadruplets, at a minimum, has
certainly been decreasing. The last year
for which we have data is already four years ago but, even then, you could see
that the triplet rate was declining and, also, and dramatically so, the
quadruplet or worse rate.
[Slide.]
One
factor in IVF success that continues to be a thorn in all of our sides is this
very strong effect of a woman's age.
Apart from substitution therapy with donor eggs, we have not really been
able to lick this one with in vitro fertilization. These are the published results on the CDC's
website from 2000, the top line being pregnancy rate and the bottom line being
delivery rate.
You
can see that, by and large, the pregnancy rate holds together pretty well until
the mid-30s and then declines with each year, almost being a zero percent
pregnancy rate at 45.
[Slide.]
The
flip side of that is miscarriage which increases with those same years. Again, this is not something that we have
been able to work around using in vitro fertilization.
[Slide.]
In
those women with older age, the only solution that has proved rather effective
is to become a recipient of donor eggs.
This is an example of a study actually done with this SART CDC dataset
over a three-year swath in which you can see that the clinical and ongoing or
delivered rate among women using donor eggs stays good and high until the late
40s. So this is a solution for women who
are running into difficulties with their own eggs, not necessarily one that
appeals to everyone but it does work and it does tell us that the problem of
being 45 or 46 is not the uterus or the body, in general. It is the eggs, themselves, because, with
substitution therapy, that probably disappears.
[Slide.]
I
also mention that in the United States, we have had better success than in
Europe with our therapies. Again, the
last year for which we have got comparable data is '98. In that year, IVF worked 10 percent better
here than in Europe, donor egg, 9 percent better and frozen cycles, 10 percent
better.
There
is a cost to that, in part because we, in the States, are typically putting
back an extra embryo or so and the cost is reflected here in the
multiple-pregnancy rates. In the U.S.,
as in Europe, most pregnancies are still singletons and most of the rest are
certainly just twins. But, in that year,
we had a 6 percent triplet rate and a 0.2 percent quadruplet rate.
[Slide.]
So
that is kind of where we have come in the States with success improving,
getting a handle on the problem of multiples, newer therapies and simpler
therapies. Now, I wanted to kind of move
our focus to considering the ovarian stimulation component.
Obviously,
IVF is a treatment process for which there are many, many influences in terms
of ultimate success rate. Ovarian
stimulation is one of the things we have to do to make in vitro work but it
isn't the only thing that influences whether or not in vitro works.
For
the purposes of this meeting, I think we want to focus on the ovarian response,
the thing that the gonadotropins can influence.
For the next several slides, that is what I am going to talk about.
We
need to understand, really, before going any further, that most women, given
the right gonadotropin stimulus, can be made to produce multiple eggs in a
cycle. But there is quite a bit of
individual variation here. Some women
can make a lot of eggs. Some women can
make very, very few eggs. Those
differences we consider to be differences in ovarian reserve.
Since
there is a wide range here, we have to adjust to that range in terms of how we
would manage the stimulation, and you will see that as the slides play
out. All of this has implications for
how one might assess the efficacy of gonadotropins which, again, is the point
of this.
Let
me use this as sort of an orienting slide.
I think we all know that women are born with all the eggs they will ever
have in their life. Over their life
span, those eggs are doled out. Now,
most of them are never ovulated. Most of
them never grow much at all. But,
nonetheless, they are lost. The rate of
loss over time is fairly constant but it is logarithmic so that things go down
by an order of magnitude at each even interval.
Within
all of the eggs that are available, a very small proportion of those eggs are
available for recruitment at any one point in time. But that percentage that is available is
pretty much fixed at all points in one's life and seems to be, as I said, a very,
very small number, a thousandth of the percent, perhaps.
What
that means is that, since a woman at 25 is apt to have still a very large
number of eggs, let's say, 100,000 altogether, whereas a woman ten years later
will have a tenth of that number and a woman ten years beyond that, a tenth of
that number.
If
you apply the expectation that a fixed proportion are recruitable, what you see
is that a woman at 25, given a full stimulus to egg growth, could make 100 eggs
whereas you can give a woman at 35 the very same stimulus and get a tenth as
many eggs and, ten years later, the very same stimulus, and get one egg.
So
we need to understand that. I think that
is a very important thing before we decide how studies would be done here to
understand that there really is a ceiling within a particular cycle of ovarian
reserve. There is a potential number of
eggs but, no matter how much drug you give, you can't ever get past that
number. You can't make a 45-year-old
make 100 eggs. There is no way to do it,
given, at least, current technology.
[Slide.]
Now,
with that in mind, clinicians try to estimate what kind of an individual is
this. Is this an individual who has 100
eggs, potentially, or an individual that just has ten or five or one because
then we are going to adjust the stimulation strength to that expectation.
So,
if a woman, in fact, could be arrayed along this dimension of how many eggs are
potentially available, we are going to take a different approach depending on
where she happens to lie along this dimension.
For the purposes of IVF, we generally would say that our goal would be
to get 10 to 20 eggs. We don't want 30
or 40 because of the risk of hyperstimulation and because it seems that the
eggs, then, aren't even as good as they could be if you had fewer.
So
we have a target for the number of eggs that we bring into development, 10 to
20 for IVF, maybe three to six for ovulation induction. To reach these targets, we are going to do
things differently according to where we think the individual woman is.
Perhaps
the easiest case to understand is this one.
If we have a woman who could make 100 eggs, we want to be very, very
careful and not overdo it because, to get 100 eggs, will not only make her sick
but we won't be able to do a fresh transfer.
So, in women with a high ovarian reserve, we are going to use very low
dosages of drug.
On
the other hand, if we think we have got a woman who has just two or three eggs,
max, per cycle, we are going to throw all the drug at her we can because we
really believe there is no danger in overdoing it. We might as well get every blasted egg that
there is to get.
There
are those in the middle where we take kind of a middle course. Women in the middle can surprise you. They can underdo it and they can overdo it. So, sometimes, we guess wrong about what is
going to actually work out. But these
predictions of response do certainly influence our choice of therapy.
One
of the things that you have to notice here is that there turns out to be an
inverse correlation between the dose employed and the response observed. So it is kind of counterintuitive. You are giving hardly any drug here and you
are still probably going to get 20 eggs or 30 eggs. You give four times as much medicine over
here and you are excited if you get three, again, because of the underlying
physiology, that there is a limit in the terms of the number of eggs that a
cycle can produce.
Sometimes
that limit is so low, we are concerned that we may have to cancel. Sometimes it is so high that we have to be
very, very careful not to overdo it.
[Slide.]
Again,
clinically, how do we try to get a handle on that? It tends to be two things that we use
clinically to assess what category of reserve do we think this particular woman
is. In those with what we think is going
to be low reserve, we typically see very, very few follicles if we do an
ultrasound. We can hardly see any of
these small antral follicles.
When
we look at the ratio between FSH and LH in these women, it will typically be
high. And when we see this pattern, we
think this is probably the actual operating range of number of eggs that we
might get and, for that reason, use a very strong stimulation protocol
understanding that, even if it works, we are not going to get 20 eggs.
At
the other end of the extreme, if we think a woman is apt to be one with many,
many eggs, 30 to 80, for instance, in a particular cycle, the ultrasound might
show some of those, typically not all of them.
But, on the ultrasound, we see a very different pattern of many, many
little follicles. Here the LH tends to
exceed the FSH and, with that pattern, we are going to be very gentle and hope
that we don't overdo it.
Again,
our goal is 10 to 20 in this case but sometimes we shoot a little too high and
find ourselves getting 30 or 40 and would, for instance, cancel if we have
really guessed wrong and overdone it.
Then
the average patient, we see some follicles.
We see more typical FSH being around the same level as LH and would use
a middle-ground stimulation in hopes of getting that 10 to 20.
[Slide.]
A
consequence of these sorts of principles is that, yes, dose does directly
affect ovarian response. No matter what
category of reserve you are talking about, if you go up in the dose within that
reserve, yes, you will get more of a response.
But the dose you typically would choose to use is inversely correlated
to what you judge the reserve to be; namely, in the low responder, you are
going to use a lot of drug. In the high
responder, you are going to use hardly any.
So,
unless, in a study, we control for this, we are going to get it completely
backwards.
[Slide.]
Now,
the process of IVF is illustrated on this slide and it really revolves around
this ovarian stimulation. That is the
heart of all of these efforts to get eggs.
It typically involves, for sure, some FSH and either LH as an injection
or LH from endogenous contributions to allow us the appropriate level of
steroidogenesis to go on.
These
other things that are typically done along with the heart of the stimulation
are applied to certain kinds of patients in hopes of either better controlling
the stimulation here or augmenting it, as you will see in the slides that
follow.
[Slide.]
What
I have just flashed up there in these little red lines are supposed to be
illustrative of the change in the FSH levels that occur when you do these
things. So, when you give FSH
injections, for instance, the FSH level goes up. That is what the point of it is.
[Slide.]
If
you give luteal Lupron, you get this initial little flare in endogenous FSH
which lasts a few days but then turns into a suppression of LH below baseline
and a suppression of FSH below baseline.
That is used in one particular patient type I will discuss in a minute.
If,
instead, you use this so-called microdose flare, a very small dose of Lupron,
you get this initial flare but it stays up forever. It really never turns into suppression and so
can be used to augment the stimulation throughout.
[Slide.]
Then
the antagonist of GnRH shuts off without any kind of a flare effect the FSH and
the LH secretion instantly and is typically used simply to obliterate the
potential for a premature LH surge.
[Slide.]
So
I am going to give you kind of an example of how these are applied to patients
of different response types as we would use them in our clinic and I think many
clinics would do something like this, if not the same thing, but certainly for
the same kinds of reasons.
Among
low responders, what we are trying to do is stimulate very hard, not only with
the exogenous use of gonadotropins but by getting the body, itself, to
contribute extra FSH by using this dilute Lupron or microdose flare approach
because we can't really have too much FSH stimulation.
In
the average patient, we have now switched to antagonists because it minimizes
shots. You often reduce three weeks
worth of shots by making this shift. We
still rely on the gonadotropins as the primary vehicle for inducing follicle
growth and simply add the antagonist at the tale end once the risk of a surge
starts entering into the picture.
And
then the high responders are ones that we really want to dampen down quite a
bit and would typically put them on pills in the month before and also on
Lupron which will downregulate their endogenous secretion so that the only
stimulation they see, once they get underway, is that from the
gonadotropins. The dose of that
gonadotropin is apt to be a low dose as well.
If
all goes well, we hopefully will see, on ultrasound, a good number of follicles
growing and, upon retrieval, get eggs from most and we would expect the
majority, we hope, to be mature and with placement with sperm, or injecting
sperm into those mature eggs, we would hope that most of them would fertilize
normally.
Among
those that fertilize normally, some, but not all, we would expect to divide
normally and, amongst those dividing normally, we are going to put back some at
the point of transfer. Now, you can see
there is a range here. The reason for
the range is that an embryo from someone who is 30 is much more apt to implant
than an embryo from someone who is 40 even when they look exactly the same.
So
there is a choice point here that hinges a lot on not egg production, per se,
but rather on embryo quality which can have almost nothing to do with egg
production. If there are extras, they
can be frozen. Everyone with me on that
point?
[Slide.]
But
I alluded to the fact the while we use the gonadotropins to achieve a certain
quantitative response, namely 10 to 20 eggs, if it works out well, there are
other very important factors relating to quality that come into play typically
past the point that we can readily observe.
Let
me tell you what I mean. Consider a
32-year-old going through IVF and a 42-year-old going through IVF. Unless this older woman is really in dire
straights, we still might be able to get the same number of eggs from her as a
32-year-old if we get our stimulation approaches correct.
So
we get a certain number of eggs in both situations and about 85 percent of them
will typically be mature and 70 percent of them will fertilize and
60 percent of them will turn into pretty good embryos three days out, and
half of those might go on to blastocysts.
Those percentages are apt to be exactly the same whether or not we are
talking about an egg that came from someone 32 or 42.
But,
beyond the point that we have got these blastocysts, the age matters a
lot. In the 32-year-old, putting two
blastocysts back will give a very high pregnancy rate and a relatively low
miscarriage rate whereas, at 42, the story is very different, low pregnancy
rate and high miscarriage rate. Even
though we started with the same quantitative material, we ended up with a very
different outcome, at least as judged at the point of pregnancy.
[Slide.]
Here
is sort of a picture of the same thing.
What this shows is potentially two different women. Let's say this is the 32-year-old on the top
row and this is the 42-year-old on the bottom row.
Again,
odds are we can probably get the same number of eggs from both women. As the days go along, the behavior of those
eggs in the lab may be indistinguishable.
A good proportion of the eggs will fertilize. A good proportion of those that fertilize
will divide and divide. So we may end up
in the very same position come the morning of transfer. But, all along, there has been stuff that is
important that we have never been able to observe; namely, which of these eggs
are normal.
The
younger woman is, statistically speaking, much more likely to have a normal egg
than an older woman. Those differences
are invisible to us in the laboratory, by and large. But, again, let's, just for argument sake,
say this 32-year-old who made these twelve eggs really had three good ones and
nine klunkers. Of these three, two
fertilized and carried on and turned into two blasts.
If
we put these back, she is apt to get pregnancy and she may even have
twins. But the 42-year-old may only have
had one good egg and it didn't fertilize.
It didn't interact with the sperm appropriately and turn into a normal
karyotype.
So,
even though we saw development, past that first day, we really had no chance
for pregnancy left in that cohort of developing embryos. So, again, it is important to understand that
there are really two categories of phenomena going on here. One is quantity and the other is quality.
We
can control quantity to some extent by our dosages but we can do nothing to the
quality. It is just part of the process
that is largely invisible to us at least clinically. Now, Dr. Keefe alluded to some technologies
that may be brought to bear in upcoming years such as biopsying and embryo like
this and testing its chromosomal constitution.
If
you could do such a thing reliably and relatively inexpensively, then you might
know that there was really never any chance here and to dissuade a woman like
this from trying again. But, at this
point, it is not a widely practiced tool.
[Slide.]
The
best predictor of the quality of an egg or an embryo seems to be the age of the
woman. In in vitro, that quality decline
is depicted here out of a study of a number of years ago. Again, it is important to understand that,
and I may not have said it clearly before, that, within the laboratory
evaluation process, a 42-year-old embryo typically looks no different than a
32-year-old embryo. So those age
differences that are important in terms of pregnancy outcomes are largely
invisible to us in the lab. The
fertilization rate is the same in older eggs.
The development rate is the same amongst older eggs.
But
we know that the probability of one of them taking is very, very different
according to age.
[Slide.]
So
we have got quantitative and qualitative effects that are strong influences on
pregnancy rate. The best predictor of
the quality seems to be the maternal age.
The best predictor of the quantity seems to be the ovarian reserve and
how you run your stimulation.
[Slide.]
In
the end, you can see, in this slide, that both factors are very, very
important. These are, again, some SART
CDC data based on a study that has been submitted for publication looking at
two-years worth of IVF data in this country broken out not only by age but by
an estimate of ovarian reserve.
[Slide.]
We
have already talked about ovarian reserve.
It turns out that, for most clinics, the most convenient marker of
ovarian reserve is FSH and the higher the FSH is, the worse the reserve
is. FSH normally is under 10 always
unless you get into some egg problems and, in menopause, it is going to be a
100 or more. So, in these normal women
trying to get pregnant, you always hope to find the FSH to be low because then
you hope that you are really in a situation with high ovarian reserve.
But,
as that FSH goes higher and higher and higher, the reserve goes lower and lower
and lower. You can see how important
this is. Not only within every level of
FSH is age an issue, but within every age, reserve is an issue. Okay?
These trends occur even though clinically we are trying our darndest to
counteract them.
The
ones with high age or high FSH are the ones getting the high stimulations, the
very, very strong dosages of gonadotropins and they are also the ones in whom
we are putting back every embryo we can get our hands on. And yet, pregnancy rates, even so, decline.
So
these two factors of age and ovarian reserve are really fundamental influences
on pregnancy.
[Slide.]
A
general strategy clinically; we typically would adjust the stimulation strength
to the predicted ovarian reserve in hopes of getting into that sweet spot of 10
to 20 eggs. That is what
gonadotropins do for us.
But
we also, then, at a later step, a subsequent step, would adjust the number of
embryos to be transferred according to our estimate of their quality. If they either are not good looking or are
from a woman of advancing age, we are apt to put back more to try to
compensate.
But,
in a way, these are different components of an overall treatment strategy. We deal with this thing first, how much drug
to give in hopes of getting a certain number of eggs and then, subsequently,
how many embryos to return.
So
I would argue that, in terms of assessing gonadotropin efficacy, we have to
understand that both the FSH and the LH are playing critical and complementary
roles. I will go into some of this in a
minute. We certainly need FSH to get the
follicles growing, the eggs to develop.
This is the part that the clinicians are worried about when they pick a
protocol and adjust the dose and strength of stimulation.
But
FSH doesn't have a whole lot to do with the production of the necessary
hormones of estradiol and progesterone.
It can only help once LH is in the mix.
LH, on the other hand, is necessary for estrogen production. Without appropriate estrogen production and
appropriate LH tone, even though you can get follicles to grow, you won't get
pregnancies out of it.
So
both are needed. Maybe, since both do
different things, we need different measures of efficacy for these different
hormones.
There
has been an ever-increasing understanding, I believe, at least clinically, that
LH does have a role to play and that there certainly can be such a thing as too
little LH to foster appropriate follicle growth or healthy follicle growth and
there may, in fact, be too much as well as is typical for very bad PCO
patients.
So,
for LH, we are typically, in a clinical setting, trying to get kind of a
permissive dose of LH to allow everything else to run the way it is supposed to
and then titrate the FSH dose up and down to get the number of eggs that we
would like.
[Slide.]
In
considering this a little bit further, I wanted to highlight a few of the
things that affect egg production. FSH,
obviously, is sort of the driver. But,
as I just alluded to, other things matter as well; LH tone during the
stimulation. That means a few
things. How much of the analogue are you
using? Did you use birth-control pills
in the prior cycle? Are you using hMG as
your stimulating drug or pure FSH and are you using metformin.
All
of those clinical tools are affecting LH tone and LH tone, in turn, affects
what good comes of the FSH you have been given.
The use of hCG as a trigger is also important and all of us in clinical
practice have probably had the unfortunate situation where a woman goes through
all the trouble of taking stimulatory drugs for ten days but doesn't take her
hCG and we get zero eggs.
It
also turns out that, at least within our practice, the doc doing the retrieval
will affect how many eggs you get out of that ovary. That is another thing to keep in mind as
studies are being designed.
[Slide.]
Let
me talk for a moment about this LH phenomenon.
I know this is a very busy slide but I think it helps us understand the
ways in which both FSH and LH are important to successful treatment. This was a study in which the Ganirelix in a
preclinical trial was given at varying doses to figure out how much of this
GnRH antagonist was necessary or desirable to achieve orderly folliculogenesis.
These
were cycles in which the stimulus was pure FSH and there was no
downregulation. So, endogenously, there
was a little bit of LH in the mix. The
Ganirelix was used to titrate that endogenous LH. With a very little dose of Ganirelix, your
endogenous LH was still pretty high, 3.6.
But, as your Ganirelix dose as increased ever higher, the effect on endogenous
LH secretion was ever stronger to the point where he practically turned it
entirely off. Okay?
Again,
a fixed dose of FSH in all these cases.
Now, because you are no longer making LH at these high levels, and LH is
critical to steroidogenesis, when you got deep into the stimulation, and
normally would be making a good level of estradiol, instead, with high doses of
Ganirelix, you were making very little estradiol because you had hobbled the
system from being able to produce estradiol at high efficiency.
Now,
that influence had nothing to do with your ability to, nonetheless, grow
eggs. At all of these doses of
Ganirelix, the FSH still caused the same number of eggs to grow. And, in fact, the fertilization in the lab
and the development of those embryos in the lab was also unaffected. So, for all you knew, it didn't matter that
your estrogen was high or low, or your LH was high or how, because you ended up
with the same number of eggs and embryos at all of these doses.
But
it did matter. It did matter, at least
to pregnancy outcome, and that is shown in the graphing part here at the
top. Let me first talk about the
dark-blue bars, the pregnancy rates. You
can see that they are pretty high up to the dose of 0.25 milligrams but low
thereafter. You can also see, in the
light-blue bars, that the implantation rate or probability of an individual
embryo taking really paralleled the pregnancy rate and was highest with this
0.25 dose.
Lastly,
in the red, you can see that miscarriage was a very common event when these
very high doses had been used. What does
this tell us? I think it tells us a few
things. One of them is, again, evidence
that FSH is the driver for folliculogenesis.
No matter what your LH tone is, you can probably still force egg growth
with FSH alone. But, in terms of
clinical success, LH has a huge role to play and there really may be a sweet
spot where you can have too much but, certainly, too little LH to permit the
eggs to be of any use.
[Slide.]
Another
factor that can get in the way of seeing clearly an FSH effect is
metformin. This is, perhaps, a good
thing because we have known for years and years that PCO patients in IVF may
make lots of eggs but still are less likely than many others to get pregnant.
So
Laurel Stadtmauer did this study a couple of years ago in which a group of PCO
patients were randomized to go through standard IVF either without any
metformin or with metformin. Metformin
is an insulin-sensitizer that has now been commonly applied to PCO patients
and, in many, will allow spontaneous ovulation.
But
it also had dramatic effects on what was seen in the IVF setting. First of all, those on metformin had a
dampened response to follicle stimulation.
Many fewer eggs were seen to be growing.
But this reduction had mostly to do with the smallest of the eggs
because, when you looked at how many big eggs, big follicles, there were, that
difference was much smaller than the overall difference.
At
the point of egg retrieval, there was no difference and even more favorable
with respect to metformin is the fact that, even though you typically got the
same number of eggs with or without metformin, the number of mature eggs was a
much higher proportion if metformin had been used and the fertilization rate
was higher if metformin had been used and the pregnancy rate was more than
twice as high if metformin had been used, again, with the same exact FSH
stimulation. So this is a very
significant modulator of response as well that we need to track if we are going
to be doing a study asking about is this gonadotropin efficacious.
[Slide.]
The
last example in this area that I would give is that, at least in our own
practice, depending on who the doctor doing the egg retrieval is, you can end
up with different egg counts.
This
is us over a couple of years. While the
number of mature eggs in the end was hardly different and certainly isn't
statistically different at all, this guy gets lots of immature eggs that the
other doctors probably leave behind. So
how would you control for this in a study?
Perhaps by focusing on mature eggs rather than eggs altogether or hoping
that the randomization will take care of it, that Dr. C won't happen to do a
disproportionate amount of the retrievals on your old drug or something.
But
these are influences that kind of get in the way of understanding efficacy.
[Slide.]
A
couple of other things and then I will be wrapping up. I think it is understandable to everybody in
the room that many factors, in fact, affect outcomes here. We do things in terms of stimulation to get
eggs. Eggs become embryos. We hope the embryos become pregnancy and
pregnancy becomes a delivery.
But
the gonadotropins that are the topic of discussion today here really are
tightly linked to eggs and less clearly linked to anything downstream of that
event, I believe. Again, the
gonadotropin response is affected by the LH tone as driven by metformin use and
OC pretreatment and analogues and whether you gave the hCG. If you don't, you are not going to get any
eggs. So there are a lot of simultaneous
considerations here that have to be accounted for or controlled for, stratified
for, whatever in terms of the quantitative character of eggs.
But
we also have to remember that there is this parallel quality factor going on,
that not all eggs, even though they may look the same, are the same in terms of
their potential. Consequently, age
enters into the progression here at many points past the egg retrieval. A 42-year-old with the same number of embryos
going back as a 32-year-old is not as likely to get pregnant and is
substantially more likely to not deliver than that other gal who had the same
number of eggs to start with.
And
then there are a bunch of doctor variables in here, too. Is it a good lab? Are the culture conditions up to date? What day did they do the transfer? Was it technically a good transfer? How many were put back? What kind of luteal support was given, et
cetera, et cetera.
So,
because of all of these sort of downstream events, it can be very hard to
clearly link a medication event to one that is very far downstream. And these are some of those other downstream
influences that I just alluded to.
Again,
going back to this, one might have the same starting point in terms of quantity
but a very different ending point in terms of quality. I am unaware, frankly, that gonadotropin use
actually drives this difference which would be a pertinent question if it
did. But I am unaware that, to get
twelve eggs with a certain dose here and twelve eggs with a different dose here
is the driver for what is normal and what is not.
[Slide.]
This
is embryos that, in many clinics, are put back, eight cells, three days
along. But if you wait a couple of more
days, half of those that looked pretty good on Day 3 would have not progressed
to Day 5 and would, therefore, have been much more likely to implant and turn
into a pregnancy. So, when you put them
back matters.
[Slide.]
How
normal the cavity is matters, what kind of an evaluation was done of the
cavity. If it is just a plain old
ultrasound, this big polyp in the cavity may have been overlooked. And, again, the fundamental ones that drive
this more than anything else is our ability to estimate ovarian reserve and
fertility. They, more than anything, can
give you a heads-up about pregnancy events, downstream events, past the point
of a certain number of eggs.
[Slide.]
As
an example of how difficult these things are to predict, I put this slide
up. This is old work but shows that--and
Dr. Keefe alluded to this--that, as you go from proximal events in the process
such as eggs to downstream events such as delivery, your ability to predict who
it is that going to get enough eggs, embryos, pregnancies or be delivered goes
down and down and down.
[Slide.]
There
is very, very weak predictive ability of either, in a sense, age or FSH about
who is going to be successful; much more predictive ability about eggs. In part, this is because of the difference in
the nature of these datapoints. For
instance, if you are able to pick an endpoint which can be characterized as
means, such as how many eggs you got, as opposed to proportion such as who got
pregnant, your sample size requirements are apt to be much, much lower when
means are used, even with the same difference to be detected.
[Slide.]
You
could take a 30 percent bump in the number of eggs that you were able to
retrieve because of a new gonadotropin but if you were looking, instead, for
that same 30 percent change in pregnancy rate, if it was even there, you would
have to study almost three times as many patients to see it.
[Slide.]
Now,
another very important consideration, though, is the fact that this benefit of
high ovarian response is often not even something you can see in the fresh
cycle. I don't know how to overemphasize
this point and I will just describe the slide first and then try to say it a
couple of different ways.
In
IVF, we typically try to get a lot of eggs.
But we are not going to put a lot of embryos back. So we often are in a position where we, in
fact, have a few extras that we opt not to transfer. Okay?
Again, an old study, but really not different in any of the newer
studies, in the old days of IVF, when the pregnancy rates generally were lower,
it really didn't matter whether we had a few eggs or a lot of eggs to who got
pregnant on that occasion because we were only going to put three of them back
anyway, and we had three from here and three from here and three from here.
So
far as we could tell, everybody got equally pregnant. The advantage of those extra eggs really
came, at least in this era, from the fact that they could be frozen and
transferred back in later cycles. So it
is clearly better to be in this greater-then-ten category. Clearly, many, many more people ultimately
were pregnant.
But, if you had picked as your primary
endpoint fresh pregnancy rate, you would make a false conclusion which is that
it didn't matter how many eggs you got when, in fact, it does. This phenomenon has really been seen in all
of the comparative gonadotropin trials where you might get an extra egg or two
here or one fewer egg here on antagonist.
It
makes no difference in the short run because you will always have enough
embryos to go back in the short run but it may hold a benefit that appears a
few months down the road. So this is
another reason to be a little concerned that if the initial pregnancy rate
becomes the primary endpoint that you will lose some of the effect that really
may be going on with a new kind of a gonadotropin in producing extra eggs or
extra eggs of good quality.
So,
I think that is all I want to say. Well,
let me say this. I guess I would argue
that, at least as one of the endpoints, therefore, one might want to look for
endpoints that almost are observable before you even get to the retrieval. If the doctor can have an effect on how many
eggs enter into the laboratory, that is a problem. Maybe you want to look for things that you
can see on ultrasound or measure in the circulation that takes some of the
operator dependence out of the picture.
We
can talk about what those might be over the next couple of days. I think that's it. So, again, my take is a little different, I
think, than Dr. Keefe's. Certainly, the
goal of the treatment called IVF is pregnancy.
But the treatment, itself, is multifaceted. There are different components of that
treatment.
One
of the components is ovulation induction.
That component certainly does affect what happens downstream but it
isn't the only important thing that affects who is going to get pregnant. There are many other equally important
things.
To
the extent that gonadotropins, their efficacy is under consideration, it
strikes me as most logical to try to link it to what is really happening with
eggs being grown rather than those other more distal events which are subject
to many other important influences.
Thanks.
Questions from the Committee
DR.
GIUDICE: I would like to open this up to
the committee. Dr. Hager and then Dr.
Crockett.
DR.
HAGER: Jim, that's an excellent
presentation. Thank you. I have three questions and I will ask them
individually and let you respond. You
have indicated the benefit of cryopreservation and freezing embryos. With the current technology and work being
done related to cryopreservation of oocytes, can you kind of update us on where
that may take us also regarding ethical considerations and so forth?
DR.
TONER: Well, it would certainly be nice
to be able to freeze eggs. For women who
don't have a partner, for women undergoing cancer treatments that may erode
their ovarian reserve, it would be a wonderful technology.
It
could also be used even among couples who are high-response type in which you
may say, okay, well, I am only going to inseminate eight eggs and work with
those for this transfer but then freeze everything else. If you don't get pregnant, we will thaw out a
few, fertilize a few. But there are
ethical things that come these days from the fact that we don't have an
effective way of freezing eggs.
You
know, divorce happens. Embryos are then
stuck between an impossible situation.
DR.
HAGER: Do you see a future for that
technology?
DR.
TONER: Yes; uh-huh.
DR.
HAGER: Okay. Second, regarding age and retrievable eggs,
if we could enhance the number of retrievable eggs in an older population of
patients based on the information we have regarding aneuploidy, would that
truly be a service and where do you see the future going regarding the ability
to retrieve better quality eggs in the older patient?
DR.
TONER: We don't have an ability
nowadays. Nowadays, all we can do is
push with our drugs and accept what eggs are developed and hope they are not
aneuploid. We could, as a first step,
screen them for aneuploidy and transfer only the normal ones. That seems to be a short-term tool.
But,
in the long term, obviously, it won't be a good solution. We don't understand what it is that makes an
egg recruitable. At this point, we just
have to accept it for what it is. But
there may be some cocktail of factors that could take the very limited supply
of eggs from an older woman and make a higher proportion of them available for
recruitment. But we don't know how that
would work at this time.
You
know, take an ovarian biopsy and inducing these primordials to grow in the lab
is something you can dream about but it isn't there now and it really wouldn't
get around the aneuploidy problem. We
think the aneuploidy problem is sort of preexisting, absent something like
cytoplasmic transfer or nuclear transfer.
There
is some question that the aneuploidy may or may not be preexisting. Certainly, if it is already an aneuploid egg,
you are probably not going to be able to do anything with it. But it is known that eggs from older women
don't have near as many healthy mitochondria so they are kind of
underpowered. And it may be that some of
the aneuploidies developed in the growth process that weren't really there at
the beginning. So if you could give them
adequate energy, maybe it wouldn't have gone awry at near the same rate.
That
was the thought behind cytoplasmic transfer and nuclear transfer. But that is not permitted. We can't do that work at the current time.
DR.
HAGER: Finally, with the rate of
multiples decreasing, probably because of limitations on transfer or
self-imposed limitations, is that information transmitted to patients in a
similar manner, do you think, by all centers.
Do you understand what I am saying?
DR.
TONER: Is every center working to reduce
the number transferred or--
DR.
HAGER: No. Is that information being transmitted to the
patients based on that risk? Do you
think that everyone is making that information available, that risk?
DR.
TONER: The risk of multiples within that
practice?
DR.
HAGER: Not only within that practice but
based on the number transferred.
DR.
TONER: Yeah; I think so. I don't know that every center has a handout
describing it, but most centers that I am aware of, if not a handout, have a
discussion on the day of the intended transfer about what happens if we put
back three, what happens if we put back two.
DR.
HAGER: Is SART monitoring that?
DR.
GIUDICE: Dr. Brzyski, do you want to
respond?
DR.
BRZYSKI: No. Actually, I wanted to ask another
question. But I would say that, you
know, one of the--speaking about monitoring.
Everyone's program reports their multiple pregnancy rate to the
national--you know, that is published.
Also SART members, when a center undergoes validation, which is a process
whereby there is a random sampling where cycles are examined by the validation
committee from SART. This is partly
supported by CDC to get a handle on data quality so the records at the Center
for that cycle are examined and compared to the data that are submitted to the
CDC to test the accuracy.
Part
of that visit for SART members includes exploration of practice issues
including, again, a random sampling of cycles, were the number of embryos
transferred in that cycle consistent with the SART ASRM guidelines for transfer
and, if not, was there some documentation of why there was a variation from
that practice.
That
is one of the criteria that are used to determine ongoing membership in
SART. So that is something that is
done. Now, each year, about 10 percent
of IVF programs are visited by validation committee members. So there is a random sampling of centers,
also.
Does
that clarify? Now, can I ask my
question? We talk about ovarian reserve
clinically as something palpable. But I
wanted to ask you your comments regarding the ability to determine ovarian
reserve in terms of the way that we can determine--if someone has blocked tubes
or no sperm, it is a very black-and-white issue.
But
what do you think our positive predictive value or negative predictive value of
identifying problems with ovarian reserve is with current technology? Is there a best test? Should we be critical of current technologies
in determining that, what is in the future?
DR.
TONER: Well, the best test is not one
that is used most times and really would be giving everybody a lot of drug and
seeing how many eggs they do grow because that is what we are really trying to
get a handle on. But it is impractical
and expensive and it will make some women sick.
So,
instead, we use other things. The basal
FSH level on Day 3 of the cycle is the most widely used. We actually have also looked at LH because
the ratio, as I alluded to, seems to be very predictive of response. We have known for years that women with PCO
have an LH, an exaggerated level of LH, with respect to their FSH. The people with low reserve are the opposite.
Another
convenient metric for most of us is simply the ultrasound. If we take a look at a gal early in a cycle,
how many of those little follicles we see is also highly predictive of how many
eggs she can be made to grow. So those
are the primary clinical tools, I believe.
DR.
GIUDICE: Dr. Rice and then we will come
to this side of the table.
DR.
RICE: I enjoyed your presentation but I
do think there are some contradictory statements that I would kind of like for
you to help my clarify. On one hand, you
say that the number of oocytes retrieved is important because it will impact
pregnancy rates, maybe not in that first cycle but in subsequent frozen cycles
if there are enough embryos left over.
But
then, on the other hand, you recognize that regardless of the number of eggs
retrieved for an individual woman based on age, ovarian reserve, et cetera,
that there may be only one or two eggs in that cohort that are ever going to
lead to a pregnancy.
So,
when we look at gonadotropins, do we only assess them for the number of oocytes
they produce or should we really be looking downstream, looking at the
fertilization rate of those oocytes that are produced by that specific
gonadotropin and then, finally, looking at the pregnancy rate because I think
that is the big question of how we should be judged, so when we set up these
clinical trials, we are asking the right question of that gonadotropin.
DR.
TONER: Yeah; I think that is why we are
all here. My own view is that the thing
the gonadotropins do is induce follicles to grow. The potential follicle is kind of on the
launching pad, will be permitted to grow if they see enough FSH. But the FSH that is used doesn't determine
whether or not they are aneuploid. That
is determined by other things, age being a convenient marker, typically.
So,
while obviously this is all being done for the purpose of pregnancy, my fear is
that if you use pregnancy endpoints, then you would--in terms of evaluating
gonadotropin efficacy, you would probably have to restrict the range or at
least stratify by those other dimensions such as age and reserve that we know
also matter and might predict the aneuploidy piece.
DR.
GIUDICE: Going up here. Dr. Crockett, please?
DR.
CROCKETT: Thank you. I also enjoyed your presentation. I want to talk a little bit more about FSH as
a determinant of ovarian reserve particularly from the standpoint of when you
look at the graphs about FSH declining with women's age increasing, it looks
like a nice linear graph. But we know
that each woman within that graph is, in essence, an n within herself and that
FSH and ovarian reserve can fluctuate within a woman. For instance, when a woman starts to go
through menopause, ovaries don't just decline gradually. There are some cycles where they ovulate and
some cycles when they don't.
It
is also my understanding that there can be sort of transient ovarian failure in
even younger women where it appears like they are not ovulating or their FSH
may be elevated for a period of time and then it goes back up to a normal level
and they are able to conceive.
Long
way of asking a question, but my question to you is how do you take these into
account in dosing the gonadotropins or should be we taking that into account
when we look at the safety and efficacy of these medications?
DR.
TONER: I think most of the clinicians in
the room would agree that there is some month-to-month difference in ovarian
responsiveness and in measures of ovarian reserve. You might have a high FSH this month not
followed by a high FSH next month. This
cycle, with a certain dose of stimulation, you might get ten eggs. Next month, same stimulation, you might get
14 eggs. So there is a bit of difficulty
in this sort of one-to-one mapping.
Every cycle isn't the same.
But,
at the same time, I think you would get argument from a lot of the clinicians
that people move wildly from one category to another. A woman who is given a strong stimulus one
month and makes four eggs is never going to make 20 eggs, never, no matter what
her FSH is next month or next year.
At
the same time, a woman who makes 40 eggs is never going to make two within that
year unless you hardly give her any FSH.
So, in terms of the full range of ovarian reserve, people tend to stay
where they are. Over time, they tend to
run down hill.
The
problem of fluctuating predictors--FSH, for instance, can be high one month,
low another--has led, again, most clinicians to adopt the view that the highest
one you ever had is the real one because that tends to be the best predictor or
responsiveness. It has been done three
or four times in different studies.
If
you have a high FSH of 14 this time, and you say, well, that is a bad cycle,
obviously I will wait until it is low.
And you wait until it is low and they still don't make a normal number
of eggs. I am not sure that the
ultrasound assessment is subject to that level of variance, though. I think the basal antral follicle count that
a lot of programs would do would be subject to much less of this noisiness that
FSH can have.
DR.
GIUDICE: Thank you. Dr. Macones?
DR.
MACONES: I think you just partially
answered my question. You presented a
great slide looking at retrieval rate by physicians suggesting that looking at
retrieval rate probably isn't a great idea if we look at these gonadotropins.
Again,
you suggest using ultrasound as a primary measure, of course, assuming that
ultrasound is reliable and has good intra- and inter-observer reliability. Is that the case? I assume it is, but--
DR.
TONER: I think it is until you get to
lots of follicles, lots and lots of follicles, because then you will find some
clinicians say, I can't measure 45 follicles.
I lost track of the last three anyway.
But I think, within the normal operating range of zero to 20, if the
question is how many follicles are there and are they bigger than 14, there
would be a lot of reliability in that kind of an assessment.
DR.
GIUDICE: Dr. Lewis? Please go to the microphone.
DR.
LEWIS: Thank you. I enjoyed your presentation. I think you raised a lot of important issues
one of which, of course, has to do with aneuploidy screening. Aneuploid eggs, I am sure, are very important
but, at this point, we don't have any way of assessing what baseline
aneuploidic rates are.
We
believe they would increase with age but we just don't know. So, to use that as a measure of how effective
a gonadotropin is I don't think would be something we could practically do at
this point in time.
I
do want to just comment on your slide showing that having some frozen embryos
would give us another measure of efficacy of a drug, but I think that is
subject to tremendous inter-laboratory variation. We did hear Dr. Keefe say that if you had
healthy embryos, they would be frozen.
That is something that is done in a lot of centers and that is going to
vary according to what kind of quality to laboratory has, what kind of culture
system they are using, whether they are freezing at the one-cell or blastocyst
stage. So I don't think that that would
be something that would be practically useful.
I
wonder if you and, perhaps, people from the FDA could comment on what kind of
trial designs are used in European centers where many of these drugs are
approved for use in ART cycles as they may not be in the United States. What endpoints do they use there?
Then,
finally, just two small comments. If you
could also comment on assay variation, LH and FSH. A lot of centers are using different kits
which may not give the same exact values.
Lastly, co-culture, you commented on as not being done because it is not
safe. It is really an aside, but I do
think that there haven't been safety concerns raised about autologous
co-culture of embryos and there are a few centers that are doing that.
DR.
TONER: I am not sure that there is any
evidence that it is unsafe. I think the
judgement was that it is not known and, until we know, we won't proceed with
the nonautologous.
The
European trials; I have not been inside the regulatory systems there. Typically, what we see are the published
studies which, as you can imagine, typically report all the endpoints. They are typically comparative trials with
blinding and multicenter and that kind of deal.
What you typically see in
them is similar efficacy, again, at least with respect to fresh pregnancy rates
because everyone is getting the same number of eggs back, embryos back, even if
they got very different numbers of eggs initially and that you would see, for
instance, that antagonist trials have typically shown two fewer eggs than in
the other approach and one fewer embryo than the other approach. But it didn't matter to the pregnancy rate in
the short run.
The
frozen rates, I wasn't arguing as something that you probably should include
for the reasons you alluded to plus the reasons of years. I mean, when are they going to get around to
getting them back--you never get an answer--but, rather to show that the
differences that may, in the long run, be meaningful to the patient are
inapparent in the short run, if you use pregnancy as your endpoint.
DR.
GIUDICE: Dr. Slaughter, will you be
addressing any of the clinical-trial endpoints in your talk today?
DR.
SLAUGHTER: I will be addressing just
some of the applications that have come through to the FDA and the actual
endpoints that were used in that trial, in those trials.
DR.
GIUDICE: Okay. Thank you.
Dr. Layman?
DR.
LAYMAN: I had a comment on the ovarian
reserve. According to John Collins, at
least, who has done a lot of the work on the positive predictive value, at
least what I heard him say six months ago was that Cycle Day 2 or Day 3 FSH was
the best predictor, the estradiol wasn't good and HIPN-B wasn't good and I
can't remember if the clomiphene challenge was as good as FSH, but I kind of
think it was either not quite as good or, because it is less involved, was
preferred.
But
the other thing to remember, of course, that really the only part that is
predictive is that, if the FSH is high, you predict a poor outcome. For some of the members of the audience, if
the FSH is normal, that certainly doesn't guarantee a good stimulation. It is only that if the FSH is elevated, there
is a high predictive value with a poor response.
DR.
GIUDICE: Thank you for your
comments. Dr. Lipshultz?
DR.
LIPSHULTZ: As the only urologist here, I
think I kind of keyed in on your statement that with ICSI, if there are ten
sperm available, then, basically, there is no male factor. That, unfortunately, is a general consensus
and, unfortunately, it is not true.
A
man who produces ten sperm, obviously, has a disease and deserves the same
amount of evaluation as the female. The
question becomes one of, given these patients who do have a disease process, we
know now that these normal-looking sperm have a very high rate of aneuploidy
and we are learning each year of the increased genetic problems that these men
have that, in fact, probably are one of the reasons why they are not producing
sperm.
So,
your end result, then, will be embryos with increased abnormalities and, perhaps,
children with increased genetic problems which goes back to the question about
how to look at this outcome in terms of ICSI and IVF.
DR.
TONER: Yeah; I grant you that I
oversimplified the system. I was trying
to make the point that, before IVF, before ICSI, was available, men with few
sperm were not well helped by IVF at all but that ICSI has at least permitted
fertilization and pregnancy to be established.
While
there are some concerns, admittedly, that there are higher sex aneuploidy rates
and other things with the pregnancy outcomes, themselves, still the biggest
study is Van Steerigum's and the rates of problems are not astronomical. They are higher than the background, higher
than the reference population, but not "no go" kind of rates, in my
opinion.
DR.
GIUDICE: First Dr. Emerson and then Dr.
Keefe.
DR.
EMERSON: I guess my questions are,
again, relating to this question of the egg production as being the
endpoint. Do we actually have evidence
that says that this FSH regimen can't affect the aneuploidy rates in
these? Do we have any baseline rates of
what that should be and how it has changed by the FSH regimen?
DR.
TONER: Not that I am aware of. But I would say that the rates that are
observed line up fairly nicely with the incidence of no pregnancy or failed
pregnancy in natural populations.
DR.
EMERSON: Yes. But we are also addressing the idea with new
treatments. This is a problem with any
surrogate endpoint is that the validity of the surrogate endpoint is an
interaction between the treatment and the disease. So the idea is that, just because you have
shown that something is a perfectly good surrogate in one treatment does not
mean it would necessarily be in another treatment and that we may have one
regime that doesn't cause aneuploidy and another one does and that would be the
pregnancy rate.
DR.
TONER: Absolutely.
DR.
EMERSON: I will note that, of course,
your evidence that you are saying that we need to consider the effects of
cryopreservation is, in fact, based on the idea that it affects the pregnancy
rate, not the number of eggs produced.
But
I guess my other concern, as we are trying to talk in generalities here, is
where there are differences in the FSH-LH combination and that we are talking
about that, and where you have suggested that the LH level has an impact, and I
am presuming--I am not too knowledgeable on the nonstatistical aspects
here--but the idea of the uterine environment, the uterine effects, ought to be
able to be affected somewhat by the FSH and LH and do we have very much data on
how the subsequent, the implantation of cryopreserved, might different from the
fresh cycle and whether any element of differences there can be the regimen
that goes in before the--for the harvesting of the eggs relative to not having
that cycle just before the implantation.
DR.
TONER: That model has not been very
instructive because two things are changing.
I mean, yes, you have a more natural endocrine environment in a frozen
cycle but you have also got an embryo that was frozen. So the two things may cancel one another out.
DR.
EMERSON: A surrogacy.
DR.
TONER: Yeah. Another model that has been done to try to
get the same answer involves, for instance, egg donors who might take a few
embryos back, themselves, and give others, also fresh, to another woman whose
uterus has been prepared in a more natural way.
There,
the evidence, in small studies, has been pretty contro--not controversial but
there is a group of three or four studies that I know of that showed no benefit
of them going back into a more natural cycle and, two, showing a trend favoring
the more natural cycle as the better environment.
You
can also look at those who happen to make a lot of estrogen and those who
happen to make a little and that will modulate the uterine milieu. Again, that doesn't seem to be very
instructive because, even though the high levels might, other things being
equal, be averse, they typically come from the women who are younger, making
more eggs, et cetera. So it is an
important question but it has been a tough one to answer.
DR.
GIUDICE: Thank you. Dr. Keefe, you had a comment?
DR.
KEEFE: Sorry to ask this with my back
turned to you but a comment and then a question. The comment is that you kind of circled
around the issue of nuclear transfer and cytoplasmic transfer, especially in
the context of your introduction where you emphasized the freedom that ART
developed in the U.S. and the advantage of that.
I
think it is important to put it on the table.
There is not a shred of evidence, not a shred of clinical evidence
whatsoever, that either of those procedures ever made a single difference in
anybody's life. They were totally
uncontrolled studies. In the published
study in Lancet there were 17 patients in their mid-30s who had an average of
something like 18 embryos. These women
did not have egg dysfunction the way we are talking about egg dysfunction.
The
whole story is completely based on a biologic rationale which is frail, very
frail. I mean, the energy theory is completely
lacking in evidence. Microtubules are
stored with energy. They don't need ATP
from the mitochondria. The mitochondria
are quiescent. They have no cristae,
just almost zero oxygen consumption in eggs at the time of fertilization in
humans and mice.
There
is no evidence whatsoever that there is a positive ATP driving aneuploidy in
any mammalian egg that has been credibly deduced.
Conversely,
you can imagine a number of biologic rationales that would make this a very
dangerous procedure because it is very clear that mitochondria are involved in
apoptosis and killing bad eggs that are predisposed towards aneuploidy. In recent published studies from--like,
Nature Genetics had a paper two months ago that polymorphisms in mitochondria
determine intelligence in mice.
I
don't know exactly how they determine intelligence in mice. I guess Mickey Mouse would have starred in
their intelligence testing, but it is very important in brain development. Most mitochondrial disorders, should they be
passed forward through this process, we, and others, have shown small levels of
mitochondrial DNA mutations in eggs from infertile women would only appear
later.
So
there is no way that this could be considered safe. It is germ-line gene therapy. It is very clearly germ-line gene therapy and
somebody should stop it, whether it is the federal government, whether it is
ourselves as a profession. Since we
didn't do it, I think it is very important that somebody did it. Anyway, that is an editorial comment.
DR.
TONER: And that may all be true. I agree that it is premature to be doing
those things. What I was trying to
highlight, though, really, is the fact that, for reasons that are still
mysterious, a 42-year-old egg, although it looks like a 32-year-old doesn't
behave like a 32-year-old egg. So all we
have now for those women is substitution therapy.
We
don't have a way to remedy the egg and those procedures that you allude to were
conceived in hopes that that would be a remedy.
That's all.
DR.
KEEFE: Yeah. I think we agree. The question is should we consider frozen
embryos a benefit exclusively or should there also be considered a side
effect. Consider there are a quarter of
a million embryos that are in freezers in the United States and I think up to 5
to 10 percent of those are abandoned.
There is a double-edged sword to the excess embryos.
I
agree with you that it is very valuable but, to sit down with a couple who has
their twins and now are figuring out what to do with these embryos that are
excess is kind of a double-edged--how do you see that in terms of trials?
DR.
TONER: Kind of the same way but I think
it may be a bridge technology. Again, if
we could freeze the eggs, themselves, even among married couples, that would
really be the preferred avenue so as to avoid these conundrums that we find
ourselves in.
But
I think, again, my point was that if the primary effect of a gonadotropin FSH
is egg production and one is stronger than another and produces more eggs but
it gets buried in the fact that you are never going to put as many embryos back
anyway as to show the benefit, then you wouldn't want to use the fresh
pregnancy rate as your only endpoint, or you would miss the benefit.
DR.
GIUDICE: Dr. Emmi?
DR.
EMMI: I had a couple of questions. My first is you had spoken about ovarian
reserve as being the best predictor or how people will respond. And then, later, you talked about PCO and the
fact that metformin will actually change the response in a PCO patient and we
all know that they tend to be super-responders.
How
would you factor that into a protocol since they do tend to respond
differently. Most people treat them
differently and start them on different levels of gonadotropins.
DR.
TONER: You might either require it being
used in all people who meet the criteria for PCO or balance for it, you know,
stratify by it, so that you don't end up with one treatment having an
disproportionate number of people who happen to get that adjunctive treatment.
DR.
EMMI: You used as your main protocol
called the antagonist, you said, for the average patient. How many programs in the country do you think
are probably--I mean, just average? Do
you have any idea how many are using that now?
DR.
TONER: I would guess half or more are
using it some way or other.
DR.
EMMI: But I mean in their average
patient population, I guess, is my question.
DR.
TONER: Don't know.
DR.
EMMI: Okay. Thank you.
DR.
GIUDICE: Dr. Stanford and then Dr. Rice.
DR.
STANFORD: I guess I would just like to
amplify again on the comments of Dr. Rice and Dr. Emerson in that I was a
little bit confused by--I thought I heard you say that we can't really affect
the egg quality by the gonadotropin stimulus.
But
then you had a clear study where the amount of LH clearly did affect ovum
quality, whether the LH was in the optimum range. So, to me, it seems that, at least in that
way, gonadotropin stimulation protocol does affect egg quality. So, that raises, in my mind, questions for
using just pure number of eggs as an outcome.
DR.
TONER: I don't think we know in that
Ganirelix trial whether the lower pregnancy, higher miscarriage, was actually
an egg effect or an endometrial effect.
So it could be that it did nothing at all to the eggs that would have
otherwise grown as evidenced by embryo development in the lab and had
everything to do with the fact that the endometrial development was deranged.
But
I agree that, given the nature of the structure of the study, there is no way
to know which it is because it could also be eggs that were adversely affected.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I guess this is more of a
comment. I am sort of brought back to my
early work when we used our mouse model and were looking at PMS and hCG and we
were excited about the number of oocytes that we could get and then we got
purified FSH and we were still excited about the number of oocytes we could
get.
Then
we did a study where we looked at FSH and then we looked at FSH as the trigger
for ovulation instead of HCGM. We were
still excited about the number of oocytes we got but our fertilization rate
dropped off significantly. So you can't
just stop at the number of oocytes that you get. You have got to look downstream and then
account for the other variables that affect the downstream outcome.
But
just looking at the number of oocytes is not enough when it looks at
differences between gonadotropins. You
have got to look at those other variables.
Now, the question is how far downstream do we look and then how can we
account for those or control for those confounders.
DR.
GIUDICE: Did you want to comment, Dr.
Toner?
DR.
TONER: I am not sure, in my own mind,
that it has to be downstream events. I
think, if you have the appropriate LH tone and the appropriate embryology
support, then you might see a very clear FSH effect holding all those other
things constant that has nothing to do with anything but now many eggs you get.
I
think, in the studies where we have seen problems, we have monkeyed with a part
of the system that didn't have anything to do with FSH, really, in the first
place. If you take away all the LH and
then have a bad outcome, it isn't because the FSH was a problem. It is because you mucked up with the LH side
of the equation.
So
I think it depends what kind of a--what gonadotropin you are trying to
examine. If it is FSH, and you put
parameters around what else needs to be there for me to ask the question fairly
of FSH, that would include adequate LH.
It would include metformin for PCO, perhaps. It would include adequate luteal support.
But,
with that frame, then I think you could potentially get a very clean answer
about what FSH is doing or not doing with endpoints not past egg retrieval.
DR.
KEEFE: I have a question.
DR.
GIUDICE: Yes; one last question.
DR.
KEEFE: Just a comment. It is hard to do these studies looking at the
effects of gonadotropins on egg quality in humans but there is a great study by
Barry Bavister in the hamster which has kind of a subfertility that approaches
that of the human. He took PMSG-stimulated
hamster donors and then he took naturally cycling donors, and they were both
fertilized in vivo. He then transferred
the zygotes into the horns, the right and left horn, of the hamster and found
that the development of the naturally ovulated embryos was severalfold that
of--the implantation rate was severalfold that of the PMSG-generated embryos
suggesting that there could be some detrimental effects on development.
It
is just harder to do those studies in humans without the controls. But there is evidence that, in normal donors
undergoing controlled ovarian hyperstimulation for egg donation who are not
split-cycle donors, they don't have, themselves, infertility--they are normal
unselected donors--that they have about 40 to 50 percent of their embryos that
are aneuploid. This comes from Tony
Pellicer in Valencia where they have done PGD in donors.
Frank
Barnes who goes around the country as the itinerant PGD biopsy--this is a sort
of business he has--has found similar experience working with Santimine who
has, again, it is a reference lab for PGD--there is a growing evidence that
normal donors, unselected, have high rates.
What
isn't known is if you just check their eggs on unstimulated cycles, would they
approach that level, although Placheau had found about 25 percent of
oocytes. So there may well be an effect. It is just hard to get that into a way we can
study it carefully.
DR.
GIUDICE: Any further questions from the
committee? Okay. I want to thank Dr. Toner. We will now adjourn. The committee will be having lunch at the
hotel restaurant. For the others, you
can also have lunch at the hotel restaurant and also there are restaurant names
available from the front desk.
We
will reconvene at 1 o'clock. For the
committee members, we have just distributed questions from the FDA that we have
been asked to review for the afternoon session.
Thank you.
[Whereupon,
at 11:55 a.m., the proceedings were recessed to be resumed at 1:00 p.m.]
A F T E R N O O N P R O C E
E D I N G S
[1:00 p.m.]
DR.
GIUDICE: We are now starting. I would like to introduce Dr. Shelley
Slaughter who is the Medical Officer Team Leader at the Division of
Reproductive and Urologic Drug Products.
She will be talking on Human Gonadotropins and the Regulatory History.
Dr.
Slaughter. Where is Dr. Slaughter? She will talking about that very soon. While we are waiting for Dr. Slaughter to get
to the podium, for the committee members, you have a list of questions. We have a session later this afternoon at 3
o'clock, a presentation of questions and committee discussion. We will have 13 questions with various
subparts and we have about an hour and a half to go through those.
Some
of them are--well, actually, the division has asked that we come up with
recommendations for each of these questions.
So we have a task ahead.
Dr.
Slaughter, we have already introduced you in absentia so welcome to the podium.
Human Gonadotropins--Regulatory History
DR.
SLAUGHTER: Thank you.
[Slide.]
This
afternoon, I am going to present the FDA's regulatory perspective on clinical
trials of human gonadotropin drug products.
As Dr. Shames said this morning, the purpose in convening this meeting
is for us to get some information from you and some recommendations from you in
order to craft a Guidance Document for Industry.
[Slide.]
The
Guidance Document for Industry represents the agency's current thinking on a
particular subject. It does not create
or confer any rights for or on any person and does not operate to bind the FDA
or the public. An alternative approach
may be used if such approach satisfies the requirements of the applicable
statutes, regulations or both.
[Slide.]
First
up, I would like to thank Drs. Keefe and Toner for their excellent
presentations this morning. I really
could stand up here and just throw the questions out, but I will spend just a
little bit more time. But thank you,
Drs. Keefe and Toner.
[Slide.]
Briefly,
I will review some gonadotropin drug products, give an overview of the clinical
studies for selected approved gonadotropin drug products and, hopefully, all of
the discussions that you have heard today will lead to a very productive
discussion by the committee and we all take your suggestions into
consideration, as I said, to craft our guidance document.
[Slide.]
There
are two types of gonadotropin drug products that are marketed, urinary-derived
gonadotropins and recombinant gonadotropins.
This is a somewhat busy slide, just gives a picture of those approved
products under both of those categories.
[Slide.]
The
approved indications are ovulation induction in chronic anovulatory women and
some of the labels will actually say ovulation induction and pregnancy in
chronic anovulatory women and the second indication, multiple follicle
development in ovulatory women for ART.
[Slide.]
The
goal.
[Slide.]
In
the 30 years since the FDA approved the drug Pergonal, the technology use in
the treatment of infertility and the resulting clinical pregnancy rates have
improved. I think Dr. Keefe brought this
point out very well this morning. With
that, it is time for the FDA to reexamine the clinical studies for gonadotropin
drug products.
[Slide.]
The
purpose of this overview that I will present will not be to reexamine the data
for efficacy to make any reassessment of that data but rather to give an
historical perspective on the study design, the efficacy surrogate endpoint and
analysis, and safety endpoints.
[Slide.]
I
probably don't have to have this slide, but I will just read it. "A surrogate endpoint is the laboratory
or physical sign that is used in therapeutic trials as a substitute for a
clinically meaningful endpoint that is a
direct measure of how a patient feels, functions or survives and that is
expected to predict the effect of the therapy."
[Slide.]
The
first of the gonadotropin drug products to be approved was Pergonal. It was approved on June 23, 1970 for
induction of ovulation. The second
indication was added on March 1, 1988 for development of multiple follicles in
ovulatory patients participating in an IVF program.
[Slide.]
The
data to support the efficacy and safety of Pergonal came from literature
reports of IVF data representing the clinical experience with 192 patients at
the Jones Institute over the period of 1981 through 1984 and IVF data from
Australia and New Zealand from 1979 through 1984.
[Slide.]
The
endpoint that was evaluated as this literature was assessed was the mean number
of oocytes retrieved at time of laparoscopy.
[Slide.]
Metrodin,
a FSH product, urinary FSH product, was approved on September 18, 1986.
[Slide.]
The
data to support efficacy and safety for Metrodin was also a literature review
of retrospective data from five open-label, noncomparative, clinical studies of
ovulation induction in 80 patients.
There were observational reports of ovulation and pregnancy. The medical officer felt that Metrodin should
not be approved. However, this issue was
taken before an advisory committee in 1985 and the advisory committee
determined that, even though the data to support Metrodin was sparse that,
indeed, Metrodin should be approved.
[Slide.]
The
next drug the I will talk about is Gonal-f.
It is actually the first gonadotropin drug product for which the actual
data was submitted to the FDA for review.
However, we did not see the protocols prior to submission for the NDA,
so we actually had no input into the study design and conduct of those trials.
[Slide.]
The
efficacy and safety data was from four controlled studies. Two ovulation studies were open-label, active
comparator to the drug Metrodin, phase III noninferiority studies in chronic
anovulatory women. The primary endpoint
was a cumulative ovulation rate, cumulative over three cycles of treatment. It was defined by a serum progesterone level
greater than or equal to 10 nanograms per ml.
The
IVF indication was supported by two randomized, again open-label, active
comparator, phase III noninferiority studies in normal ovulatory women. The primary endpoint was follicles on
ultrasound greater than 14 millimeters.
[Slide.]
Both
of these trials--this is ovulation induction trials, now. One was conducted in the U.S. and one was
conducted in Europe. As you can see,
these, as I stated before, are noninferiority comparative trials. Both studies show that Gonal-f was no worse
than Metrodin by 16 or 21 percent, so about 20 percent difference. The lower bound of the 95 confidence interval
suggests that it was no worse than about 20 percent than Metrodin.
[Slide.]
There
were, as I said, two IVF studies. One
was conducted in the U.S. and one was conducted in Europe. This goes back to one of the questions that
was asked earlier this morning. This was
mean number of follicles. There was not
much difference in the results between the U.S. and the European study. Again, the Gonal-f was no worse than Metrodin
by about three follicles.
[Slide.]
The
next drug was Follistim. It came in a
little later than Gonal-f but received its regulatory review approximately
about the same time. It was approved on
September 29, 1997. Again, actual data
was submitted for review to the FDA but we were not involved in the protocol in
terms of study design endpoints.
[Slide.]
Efficacy
and safety to support Follistim was from four controlled studies. One study supported ovulation. It was a single or assessor-blind study,
active comparator to the drug Metrodin, phase III, noninferiority trial in
chronic anovulatory women.
[Slide.]
The
drug Follistim was actually better or superior to its active comparator in
terms of ovulation rate with about 85 percent ovulation rate.
[Slide.]
Three
randomized assessor-blind, active comparator to either Humegon or Metrodin,
phase III noninferiority studies supported the IVF indication in normal
anovulatory infertile women. The
endpoint that was evaluated was the mean number of total oocytes retrieved.
[Slide.]
These
three studies were all conducted outside of the United States. Most of these were European trials. The largest of the trials I have indicated as
IVF Study No. 1 actually showed Follistim to be superior to its active
comparator in the total number of oocytes retrieved. The point to bring out on this one is that
this was a trial that was, indeed, powered to show a difference in pregnancy
rate and it did, indeed, show that.
I
would just have you look at the numbers because that is a point that we will be
coming back to.
Now,
the lower bound of the 95 percent confidence interval, as stated, showed that
Follistim was either better or no worse than its comparators by about one
oocyte.
Now,
at this point, the point I would like you just to take home is that we have
been using various surrogate endpoints for pregnancy. Our sponsors and their advisors indicated to
us that trials could not be powered to show pregnancy or would be difficult to
power, and you do see what the magnitude of the sample size that would be
needed to actually show pregnancy.
We,
then, as I said, looked a surrogate endpoints.
Our question has always been what difference would be clinically
meaningful in these surrogate endpoints; in other words, how do we make the
interpretation of the difference between the drug and its active comparator.
[Slide.]
The
safety evaluation on all the four examples of drug products that I gave you,
the review looks strongly at ovarian-hyperstimulation rate and multiple-birth
rate.
[Slide.]
As
you have heard, since these selected gonadotropins were approved, IVF
technology has been broadened to include adjunct procedures such as donor
oocytes and intracytoplasmic injection and there are more IVF clinics available
leading to a greater pool of patients for inclusion in studies.
[Slide.]
This
brings me to the point in the presentation where we will put the questions up.
DR.
GIUDICE: Thank you.
DR.
SLAUGHTER: We will actually put these
questions back up a little later, but just to have it, I will read through the
questions for you.
[Slide.]
Please
discuss what enrollment criteria should be used to adequately capture the
population to be studied for ovulation induction and for
assisted-reproductive-technology programs.
[Slide.]
Should
enrollment criteria be stratified by age for ovulation induction and for
ART? Should we stratify for use of
adjunct procedures such as donor oocyte or ICSI?
[Slide.]
Should
our studies be blinded or not and, if blinded, please discuss the merits of
blinding the assessor, the patient or both.
Discuss the merits of having placebo and/or active control arms in the
studies. If an active control is used,
discuss how you would define the noninferiority margin.
[Slide.]
Discuss
the advantages and disadvantages of single versus multiple treatment
cycles. Discuss the advantages and
disadvantages of powering studies to detect a difference in live birth rate or
ongoing pregnancy rate.
[Slide.]
If
studies cannot be powered to demonstrate differences in live birth rate or
ongoing pregnancy rate, please discuss the clinical relevance of the following
surrogates; the rate of patients with a presence of a fetal heart beat,
gestational sac, positive beta-hCG, ovulation rate or follicular development
rate.
[Slide.]
Is
an intent-to-treat analysis appropriate for ovulation induction? If you feel that it is not, should cycles by
analyzed per patient given hCG?
Likewise, for ART, is an intent analysis appropriate? If not, should cycles by analyzed per
retrieval or per embryo transfer. Please
discuss which safety endpoints should be evaluated.
DR.
GIUDICE: Thank you, Dr. Slaughter.
Questions from the Committee
DR.
GIUDICE: Does the committee have any
particular questions regarding Dr. Slaughter's presentation because we are
going to wait to answer these questions or discuss these questions during the
question discussion period later in the afternoon. Yes; Dr. Stanford?
DR.
STANFORD: I don't know if you know this
stuff off the top of your head, but it would be helpful to me to know the GnRH
agonists and antagonists, what were their endpoints when they were approved. What were the endpoints in those studies to
approve those products?
DR.
SLAUGHTER: The agonists have never been
presented to the agency for consideration.
The antagonists also looked at oocyte retrieval.
DR.
STANFORD: On Repronex, which is another
version of hMG, as I understand it, what was the endpoint on that because its
indication is different. It lists with
an agonist as opposed to the others don't list that.
DR.
SLAUGHTER: The history behind that is
that Repronex was originally approved as a generic drug. They came back to the agency to ask for a
change in route of administration and, at that time, they also presented new
trials that utilized GnRH agonist for downregulation.
Also
let me say that the trials for Gonal-f, I believe, were not done with
agonists. Two of the three trials for
IVF for Follistim were done with GnRH agonists.
DR.
STANFORD: But they didn't put that in
the labeling. So was the endpoint of
Repronex the number of oocytes retrieved?
DR.
SLAUGHTER: Yes.
DR.
STANFORD: Okay.
DR.
GIUDICE: Yes?
DR.
EMERSON: In the Follistim IVF study,
what was the patient population, what was the definition of infertility in the
normal ovulatory?
DR.
SLAUGHTER: I believe that it included
some male factor, I believe mild male factor, and unexplained and tubal factor.
DR.
EMERSON: And infertility was defined by
one year of--
DR.
SLAUGHTER: Yes.
DR.
EMERSON: Okay.
DR.
GIUDICE: Dr. Hager.
DR.
HAGER: Along that same line, is the
reason that there is not consistency across the board is because you were
not--the agency was not involved in the protocols?
DR.
SLAUGHTER: Yes.
DR.
HAGER: You were not requested to be
involved in the protocols?
DR.
SLAUGHTER: We did not receive those
protocols ahead of time to participate in them.
Subsequent to that, we looked at the trials for Follistim and made some
recommendations about endpoints. Again,
our recommendation, and Dr. Bennett is seated in the audience, was to look at
take-home baby. We were told that that
was not feasible and so we recommended oocyte retrieval and based our
clinically meaningful difference on the trials that we had up to that point.
DR.
HAGER: So the use of oocyte retrieval
was an FDA recommendation.
DR.
SLAUGHTER: Yes.
DR.
GIUDICE: I have a question following up
on Dr. Hager's. Then, I guess for
clarification of the advice that you would like from this committee, the
immediate short-term goal is for us to answer these questions and so a guidance
document would be developed for your interactions with sponsors before they
design their clinical trials, when they have information that they are bringing
to you? Can you shed some light on this,
please.
DR.
SLAUGHTER: What happens,
usually--usually, at this point, what we have is the sponsors will come to us
at a pre-IND stage and talk to us about the indications or applications that
they would ultimately like to bring in.
And we have ability to interact with them as they are opening their IND
and study design and to make recommendations to them at that point.
They
generally do or do not take our suggestions and conduct their studies. They come in at the time that the studies
have been completed at phase III and have another discussion with us before the
NDA is submitted. There is also--it
depends on the stage of development they are with their drug. We can have meetings with them when they are
very early at phase I, when they are at phase II or at the phase-III
development.
DR.
GIUDICE: Thank you. Dr. Lipshultz?
DR.
LIPSHULTZ: Just for my own
clarification, then, have the companies been coming to you at different stages
in terms of where they have already gone with the product or do they all come
to you prior to institution of a protocol?
DR.
SLAUGHTER: They have been coming at
different stages. Sometimes as some of
the examples I have shown you here, they never come to us until they are
presenting their application. Sometimes,
they come, depending on the drug product and I am just giving a general
overview now at a very, very early stage before they ever go into humans, and
then work with us all along the process.
Sometimes
they come in after they have already conducted some trials and to ask for
further advice. When they don't come in
at all, these are trials that have been conducted outside the U.S.
DR.
LIPSHULTZ: Do you foresee this process
changing and that is why this document becomes important?
DR.
SLAUGHTER: The trend now is for most
sponsors to come in with--to us for advice, now.
DR.
LIPSHULTZ: Before they--
DR.
SLAUGHTER: Before they submit the
application. We still do have some who
come in at a later stage, but we now have worked with a number of sponsors who
are coming in early during their development and process. For the gonadotropins, they generally come in
to discuss a phase III trial. There may
be other drugs coming down the line that may come at an earlier stage, but,
yes, the purpose is to give guidance to those--to the industry conducing these
phase-III trials.
DR.
GIUDICE: Yes, Dr. Crockett?
DR.
CROCKETT: I just have a question
regarding these guidance documents and the past history and what you foresee in
the future for them. This is kind of a
new thing to me. I am interested in
knowing do you have guidance documents in place already for other drugs through
this division? Is this kind of a book
that is being put together of guidance documents.
Then
my second part of the question is, as we have seen through these presentations,
as our knowledge of science has grown, our recommendations probably would have
changed over the last ten years. So my
follow-up question is if we draft a guidance document today, when does this
committee get to revise or look at it again and what does the division or the
FDA plan to do with this?
DR.
SLAUGHTER: Okay. I will try to answer all those questions in
order. This is not a new thing. Throughout the agency, we try to keep our
recommendations as uniform as possible and, in order to do that, we do draft
guidance documents. In our division, we
have numerous guidance documents, some that, as you know--some of the
hormone-therapy guidance documents are now in draft on the web.
What
we intend to do with this guidance document, we do realize that things change
over time which is why I am here today.
But what we intend to do with this is take your recommendations, put a
draft guidance together. That guidance
will be approved internally and then will be put up on the web as a draft
guidance for comment from the public.
Our
intent is not necessarily to bring that draft back to the committee but,
certainly, the committee or anyone else would make comments to that document at
the draft stage and we would take into consideration those comments.
DR.
GIUDICE: Dr. Hager?
DR.
HAGER: I'm sorry; I hate to belabor this
but it seems to me that what we are trying to determine is are we going to make
a difference. I heard you make a comment
earlier that the FDA recommended to pharmaceutical manufacturer X a change in
protocol but that was not adhered to. At
that point in time, then, basically you wait until the study is submitted
without those changes in protocol and then reevaluate the data; is that
correct? There is no intervention in
between?
DR.
SLAUGHTER: Let me try to answer
that. I put up these guidance documents
are just that. They are recommendations. They are not binding. What we do in order to keep our
recommendations uniform is to draft these guidelines, these guidances. If the sponsor chooses not to follow our
recommendation, then that becomes an issue that we will look at in terms of
whether it affected the outcome and we felt there was any effect on the outcome
as we review the application for our regulatory decision.
DR.
HAGER: I understand that--I thought
there is some intervention process but I guess there is not. There are no regulations--
DR.
SLAUGHTER: No. The guidances are not regulations. We would have to do that in order to make
them binding. We can only make them as
uniform as possible and give uniform advice and have the sponsor voluntarily
adhere to those guidance documents.
DR.
GIUDICE: Dr. Shames.
DR.
SHAMES: The purpose--we cannot, once we
make recommendations for trials, compel anybody to do that particular
trial. We can only stop a trial based on
safety. So people are allowed to do
essentially within certain parameters any trial they want to do. The guidance process is to make everything
more efficient for the industry, for us, so that they know beforehand basically
what we want. Then we do work with them
and try to tweak their trials so that we, all along the process, know what is
going to happen.
Therefore,
when we get the final information, we have the information we need so it is the
most efficient way to get it done. Now,
if they choose to do it some other way, it is still possible to get it approved
but it is going to be--it is a little riskier, certainly, on their part. So we are trying to get the word out of what
is the best way to do it.
Now,
in this case, of course, we are not 100 percent sure what is the best way
to do these trials so that is why we have convened this advisory
committee. Of course, when we don't know
what the best way and the company is telling us one thing and--it makes the
process less efficient.
So
if we can all sort of agree on some general parameters, then we can move
forward faster.
DR.
GIUDICE: Thank you. Any additional questions? Yes; Dr. Emerson?
DR.
EMERSON: I am going back to these
previous trials that have been done, and knowing that you gave us some
background information that were chapters out of various gynecology and
endocrinology books that gave estimates of the rates of--pregnancy rates in
infertile couples after a year, I think.
Are those widely agreed-upon rates or are those, I guess they are
quoting something 11 percent pregnancy, fecundity, rate after being
infertile for twelve months. Is that a
widely agreed-upon rate? Thank you.
DR.
GIUDICE: Dr. Stanford?
DR.
STANFORD: I guess it goes without saying
that if there is a certain approach that comes out as recommended in a guidance
document, that is basically what you are looking for in the actual approval. I mean, that is basically what you are saying
is that if this is the endpoint you are asking for in the guidance document,
that is also the primary endpoint you will look at when you are actually
approving. That is a fair statement?
DR.
SLAUGHTER: Yes.
DR.
STANFORD: One other question. This may be a real--there may be no--I am
just trying to understand, I guess, the details of the actual stated
indications but I noticed that, for Follistim and Gonal-f, they are both
indicated for both ovulation induction and ART but they list it in different
order. Is there any significance to
that, or is that just random?
DR.
SLAUGHTER: That was just how that fell
out; yes. Let me just--I had a little
bit more on this I left off the questions, one of the things that I left off
from these questions. So it will address
one of your things.
These
are the indications; induction of ovulation or some of the labels do say
induction of ovulation and pregnancy or marked follicle development and
ART. We would like your comment on the
appropriateness of these indications given all the discussions that hopefully
you will have on the endpoints and analysis.
Then,
the last thing, and I apologize that I left off this at the end, this came up
this morning about the SART data that is collected on pregnancy and about
pregnancy registries with industry. We,
as part of the process, can only recommend that they maintain a pregnancy
registry. We would like to have your
input on that, should manufacturers obtain approval for ovulation induction or
ART who obtain approval maintain an pregnancy registry. If you do feel that they should, what
information should be collected in that registry and at what point in time
should the registry be terminated?
DR.
GIUDICE: I have a follow-up comment to
Dr. Stanford and also Dr. Shames' comments.
Whenever a set of guidances are issued, not specifically to the FDA but
by an organization or a body, very often they do not accommodate for the--or
they do accommodate for "one size fits all." But, with the complexity of ART and ovulation
induction, I think it is an important issue that this is another part of our
discussion, that while these may be recommendations, clearly there should be
some allowance for "one size does not fit all" for thee particular
medications and indications.
DR.
SHAMES: It says in our guidances that
these are only recommendations. In a
field such as this, we often are open to adding to the guidance or changing the
guidance periodically. We can keep it
even as a draft guidance and still keep it public.
And
we certainly recognize that there are times when we--there is more than one way
of doing things. So that is a well-taken
point. Absolutely.
DR.
GIUDICE: Thank you. Dr. Rice?
DR.
RICE: I am assuming that, when I look at
Point 13, we would make a recommendation, if we decided to recommend this based
on future products to be approved or is there any room for the current list of
products that are approved for these indications to begin to maintain a
pregnancy registry or are you only looking to us for guidance for future
products that are going to be approved?
DR.
SLAUGHTER: I guess I would answer that
as saying do you think these are necessary for these drug products and, if you
believe they are, then I think we would certainly implicate them first with
future products but would have further discussions on ART products that are
already approved. Dr. Shames?
DR.
SHAMES: If the committee believes it is
important to have that, that will add weight to our arguments to drugs that are
already approved that they might investigate doing that. We have no way of compelling them to do that
but we would be interested in your opinions about whether they should or
shouldn't do it.
DR.
GIUDICE: Thank you. I think we can discuss that in more detail
later this afternoon.
I
would like to move on now to the Open Public Hearing.
Open Public Hearing
DR.
GIUDICE: Before starting this session,
there is a statement that I have been asked to read, and that is that,
"Both the FDA and public believe in a transparent process for
information-gathering and decision-making.
To ensure such transparency at the Open Public Hearing session of the
advisory committee meeting, the FDA believes that it is important to understand
the context of an individual's presentation.
"For
this reason, the FDA encourages you, the Open Public Hearing speaker, at the
beginning of your written or oral statement, to advise the committee of any
financial relationship that you may have with any company or any group that is
likely to be impacted by the topic of this meeting.
"For
example, the financial information may include a company's or a group's payment
of your travel, lodging or other expenses in connection with your attendance at
the meeting. Likewise, FDA encourages
you at the beginning of your statement to advise the committee if you do not
have any such financial relationships.
"If
you choose not to address this issue of financial relationships at the
beginning of your statement, it would not preclude you from speaking."
So
there are three individuals who have requested time during--okay; are the three
individuals who have requested time present?
I see one hand, two hands. Two
hands. Then let's begin with Dr. Kirsch,
please. If you would introduce yourself,
your affiliation and if you choose to
make any comments with regard to the opening statement.
DR.
KIRSCH: Thank you. Good afternoon. My name is Robert Kirsch. I am a Director of Regulatory Affairs at
Sorono. I would like to make a brief
statement to the committee and we very much appreciate your time this
afternoon.
For
more than 50 years, Sorono has been a global leader in the development of
treatments for infertility and has been dedicated to helping couples realize
their dreams of parenthood. Sorono is a
company committed to cutting-edge research, high-quality products and patient
care.
Our
complete portfolio of fertility drugs, including Gonal-f, Cetrotide, Luveris,
Ovidrel and Crinone addresses patients'
needs at every stage of the reproductive cycle.
Three of these products, Gonal-f, Luveris and Ovadrel are gonadotropin
products manufactured using recombinant DNA technology.
We
appreciate the opportunity to provide comments on the following important
issues raised by the FDA for discussion in consideration by the advisory
committee. These issues are endpoints
used in clinical trials;pregnancy as an endpoint, and clinical pregnancy.
The
design of clinical trials intended to support the registration of new products
and indications is an important subject both to the sponsors of such clinical
trials--i.e., industry--and the FDA.
Equally important is to recognize that, although in certain patient
populations for which the underlying cause of infertility has been clearly
identified or which has already been extensively researched, it may be possible
to agree on a single standard endpoint.
However,
it is imperative to avoid a "one size fits all" approach to research
in the constantly evolving area of infertility and reproductive health. The first issue, endpoints used in clinical
trials; for each population and indication studied, the endpoint chosen should
reflect the primary pharmacological action of the drug. For indications involving ART, this may be
development of multiple follicles which can be measured directly or indirectly
as oocytes retrieved.
In
ovulation induction protocols, for example, patients defined by the World
Health Organization as WHO2, an appropriate primary endpoint may be P4. Conversely, in patients defined as WHO1, P4
is not fully informative as it does not provide full visibility to other
critical components of drug effect.
Therefore,
for this population, rate of follicular growth, estrogen production and
endometrium receptivity are critical measures of drug efficacy and equally
important to P4.
The
second issue, pregnancy as an endpoint.
On the broader subject of pregnancy, this is the ultimate desire of
every patient and her physician but does not necessarily reflect the primary
pharmacological action of the drug. For
those ovulatory patients whose cause of infertility remains unknown and
unexplained, as many as 25 percent of all infertile patients, pregnancy
may be an appropriate clinical endpoint.
For
patients undergoing ART, there are other pharmacological agents used during the
treatment regimen as well as multiple additional confounding factors any of
which may impact pregnancy. These
additional factors which are beyond the control of any sponsor, must be
considered.
It
is important to note, however, that information on pregnancy has always been
collected and reported during gonadotropin clinical trials.
The
third issue, clinical pregnancy; regarding clinical pregnancy as an endpoint,
the above considerations remain.
Clinical pregnancy is defined be the National Registry, SART, by the
presence of an embryonic sac. Patients
realize that a pregnancy detected in its early stages is, indeed, a pregnancy
even though it may not always proceed to a pregnancy confirmed by ultrasound or
even a live birth.
Beta-hCG
is universally accepted as the diagnostic test for early pregnancy and the
ultimate outcome of any pregnancy does not alter the fact that a pregnancy was
established. Furthermore, in studies of
our gonadotropin products, there are many instances where a clinical pregnancy
has been confirmed by ultrasound with a fetal sac but without heart beat. Given that the majority of these same
patients achieve a successful pregnancy outcome resulting in a live birth
indicates that the most conservative approach, ultrasound with fetal sac and
heart beat, could result in applying an excessively high standard in terms of
product registration.
In
considering these types of endpoints, one must realize that, in order to ensure
that a clinical trial is adequately powered to detect statistical differences
between treatment arms, a primary endpoint of pregnancy, clinical or otherwise,
will require large numbers of patients to be studied, potentially thousands per
study, creating additional hurdles when conducting research in infertility.
This,
in fact, would serve as an additional deterrent to research in low-outcome
patient populations and in those patients who suffer from rare conditions or
diseases. Clinical development programs
will always have constraints that are not present in routine clinical
practice. Importantly, one must
determine how much is too much to ask of a particular gonadotropin drug
product.
Ultimately,
all divisions of the U.S. Food and Drug Administration must make decisions on
approvability based on the overall benefit-risk profile of the proposed product
in relation to treatment of patients and their respective underlying
disease. These considerations are never
black and white.
Therefore,
in making recommendations which may form the basis for a guidance-for-industry
document, we encourage that maximum consideration be given to ensure adequate
breadth and flexibility in aspects of study design. This will facilitate the introduction of new
drugs, treatment of new indications and improvements in the scientific and
manufacturing technologies employed in making these therapies available to
patients in the most efficient manner possible.
Sorono
has been a leader in the field of research development and commercialization of
products used in the treatment of men and women experiencing infertility for
more than 50 years and we intend to continue this commitment. We request that the advisory committee
consider carefully what recommendations can be made in order to facilitate the
clinical development and availability of new and innovative products which are
both safe and effective in the most expeditious manner possible for these
patients many of whom are currently underserved.
I
would like to thank you all again for the opportunity to share Sorono's
position with you this afternoon on some of these important issues. We look forward to hearing your
recommendations and to receiving FDA's draft guidance for industry.
Thank
you very much.
DR.
GIUDICE: Thank you. The next speaker is Dr. Kurt Barnhardt.
DR.
BARNHARDT: Good afternoon. It is a privilege to be part of this as a
public member. My name is Kurt
Barnhardt. I am an Assistant Professor
of Obstetrics and Gynecology, a reproductive endocrinologist as well as an
epidemiologist at the University of Pennsylvania. I direct the Clinical Research Center in our
department in the University of Pennsylvania and, as such, have contacts with
many industry supports that sponsor our studies including, off the top of my
head, Wyeth-Ayerst, Parke-Davis, Organon and Sorono.
I
wanted to talk briefly and add my comments on the idea of study design and
outcomes. As I mentioned, in my capacity
as doing clinical research, I have designed many of my own studies as well as
participated in many industry-sponsored studies and I wanted to speak a little
bit about outcomes and study design in that aspect.
We
all know, and we have heard some eloquent talks that infertility is a very
complex subject and, often, I can have patients, I, in my practice, that I
treat for infertility without gonadotropins and, oftentimes, I can treat them
with gonadotropins concomitant with many other therapies as well.
As
I want to point out, and as you have heard before, there are many, many factors
influencing the ultimate success of the treatment and it is not surely just the
pharmacologic agent that I choose.
I
disagree with some of the verbiage that was used earlier and I think it was
more a mistake that biochemical markers are surrogate markers of infertility
treatment. I think that what I would like
to say is that we would like to have, or, as a methodologist, you want your
outcome to be as close to the direct action of the intervention as possible, in
this case, drug therapy. The purpose of
drug therapy is, again, in this case, for multiple follicle development or
having someone ovulate that otherwise normally wouldn't.
After
that takes place, there are many factors that influence whether a women is
going to get pregnant. There are many
other therapies that we use allowing someone to pursue that goal. Some women get insemination. Some don't.
Some get ICSI. Some don't.
Age,
obviously, as you know, requires a lot as the genetics of the woman, the
receptivity of her uterus and such. But
the further downstream we move from the use of the pharmacologic agent, the
more determinants are going to affect that outcome. That makes it very difficult to design a
study based on a downstream outcome.
I
mentioned that another reason that it makes it difficult for these outcomes is,
again, the specifics of how we individualize treatment of the woman or the
couple with infertility. It, again,
varies very much on how we handle gametes, the quality of our laboratory and
many other factors that are independent to the woman alone to try to stratify
in these outcomes or to try and analyze these potential confounders afterwards,
again, makes it very methodologically difficult.
I
guess the only analogy, as I was driving down, that I could think of would be
if I was designing a new drug for the induction of labor, I would hope that
this drug would be judged on its ability to induce labor, not on its C-section
rates and not on its perinatal mortality.
Of course, those are important aspects of the drug, but they are not the
primary endpoints of the drug under study.
Another
issue I wanted to bring up was that the population is very specific and a very
savvy population and that certain studies are going to be difficult to carry
out practically in this population even though they might be a very good study
on paper. A randomized, blinded trial,
although certainly the Cadillac of studies, can have some difficulties in
patients where high drop-out for not getting the treatment they want or for
therapies that don't work is going to very much influence the outcomes and the
validity of a study.
The
same could be said for the idea of trying crossover studies or the possibility
of having multiple sequential cycles.
Please recognize that this really is an individual population and the
practicality of carrying out such studies should be taken into account.
So
the goal, really, was for me to say please maintain some flexibilities in your
outcomes. I mean, currently we are
talking about gonadotropins where the goal of the therapy is to induce
ovulation in those that don't ovulate or to induce multiple ovulation in those
that do.
We
could argue about what is the best test for ovulation. Currently, probably, the best compromise
between reproducibility and invasiveness is a serum progesterone. But, as we change and that science advances,
that also might change and we might adopt some other better marker of ovulation
of follicular development.
Indeed,
as our drugs change, as we go into subpopulations of infertile populations, we
might be talking about improving egg quality rather than egg number. If we are just talking about ovulation as an
endpoint, we are going to lose the robustness of that additional
information. Indeed, if we are talking
about a new fertility drug that, for example--and I just made this
up--maintains the miotic spindle, obviously, we can't have ovulation as an
endpoint for that kind of drug. So we
have to have flexibility on our study
design to allow for the specific indication of that drug.
So,
obviously, as a clinician, I hope all of my patients get pregnant and I strive
to maintain that. But I also know there
is a lot more than the pharmacologic agent I choose and the dose that I choose
that is going to influence that.
So,
of course, I suggest that you collect all pregnancy data as SART is collected and,
of course, miscarriage rates, ectopic pregnancy rates and OHHS are important
information. They are very valuable
information to decide whether a drug is better or equivalent or no worse, and
that is not what I am addressing in the study design. But that is information to compare and not,
hopefully, the primary endpoint to power a study.
So,
thank you very much for the chance to speak.
DR.
GIUDICE: Thank you, Dr. Barnhardt. Are there any additional comments or any
additional speakers for the Open Public forum?
Yes?
MR.
TIPTON: I am Sean Tipton, Director of
Public Affairs with the American Society for Reproductive Medicine. Our President Elect, Marian Dameler, was due
to be here today and got detained in York, Pennsylvania which,
unfortunately--it is better for people who are flying from farther away because
they are less likely to get hung up, I think.
The
ASRM does have a commercial relationship with a number of players in the
pharmaceutical industry who may have an interest in the deliberations of this
panel. Primarily, those will take the
form of advertisement or sponsorship of ASRM programs.
Thanks
for the opportunity to offer our views on ovulation-induction drugs. The ASRM is a professional association of
more than 8500 members worldwide. Our
members include the leading experts in the field of reproductive endocrinology
and infertility many of whom are around the table and in the room today.
As
an organization, we have dedicated considerable time and resources to issues
surrounding the use of ovulation-induction drugs. We have developed patient-education
materials. Our practice committee has
issued a number of related reports and in our journal, Fertility and Sterility,
there are frequently works on ovulation-induction drugs and we feel uniquely
qualified to offer a little insight and input into the topic.
Ovulation-induction
drugs are an essential component of the modern treatment of infertility with
approximately one-third to one-half of all infertile women who are having
ovulation problems. For many patients,
ovulation-induction drugs help with their ovulatory problems and, for others,
the drugs are used to maximize success of other treatments such as in vitro
fertilization.
Ovulation-induction
drugs are used with great effect every day by the members of the American
Society for Reproductive Medicine.
However, like all physicians, our members are constantly seeking new and
better ways to treat their patients.
Like any medication, ovulation-induction drugs carry some risk, each specific
product carrying its own particular risk, and we would support the approval of
new products with lower-risk profiles.
Many
of the concerns, such as reports of increased cancer risk following the use of
these products, have not stood up to increased scrutiny, but it is increased
scrutiny, more research and better data that are essential for these products
as they are for any medication.
At
present, one of the most serious potential risks from the use of these drugs is
multifetal pregnancies. Multifetal
pregnancies carry huge risk for the mother and the subsequent children. The ASRM practice committee has issues
guidelines limiting the number of embryos to transfer in ART procedures to
minimize the risk of multifetal pregnancy.
This work was done with our affiliate, the Society for Assisted
Reproductive Technology.
In
that case, the data were clear that the number of embryos transferred could be
reduced without adversely affecting the prospects for a successful
outcome. Unfortunately, the data are
less clear on steps to recommend to prevent multifetal superovulation
pregnancies. Writing in the January 2003
issue of Fertility and Sterility, the current chair of our practice committee
and his immediate predecessor wrote, "Specific guidelines for management
of ovulation-induction cycles cannot be offered because neither sufficient
evidence nor broad consensus exists. The
ASRM practice committee has no valid basis to offer specific recommendations
for cycle-cancellation criteria."
In
short, the data are not conclusive.
Clearly, more data is needed, more research is needed, more and better
medications to provide more and better options for the infertile patients in
this country are needed.
We
look forward to the deliberations of the committee and thank you for the
opportunity.
DR.
GIUDICE: Thank you. Are there any further speakers or
comments? Okay; we have a choice, now,
as a committee, either to take a break or to begin discussing one of the
thirteen questions. Who would like to
take a break? The hands are gradually
going up around the table. Let's take a
ten-minute break and then reconvene, please.
[Break.]
DR.
GIUDICE: Before we begin discussion of
the questions, there have been several committee members who have expressed an
interest in finding out what input they may have with regard to the final
document. Dr. Shames, if you would make
some comments, please, as to what the process is.
DR.
SHAMES: Okay. The process--in a general sense, the advisory
committee literally advises us on certain issues, general issues, specific
issues. Ultimately, however, your advice
is advice. It is a recommendation. We have the authority to make the decision or
write the guidance or whatever.
What
will happen in this situation where we are trying to write a guidance is, once
we have finished this and we will look at the transcript--everything you say is
being written down. We will have a
direct transcript of all this. Our staff
will write a guidance. It will be called
a draft guidance and will be posted publicly.
You,
everybody, anybody and everybody, will have a chance to make suggestions
regarding our draft guidance including you.
Now, you, as our advisors, have somewhat of a special status in that we
can talk to you directly and you could recommend to us directly. We can speak to you on a more direct basis
than other people.
But
the pharmaceutical industry will make recommendations. Public-interest groups will make
recommendations. And then we will
ultimately, if the process goes well, prepare a final guidance and that will go
on the web. We may ask you, again, about
the final guidance. We can do that. But, ultimately, we are the ones that have
the authority to write the final guidance and put it out there.
So,
if that is helpful. But, as advisors,
you have good access to us. So when the
draft guidance goes up, you should feel free to be aggressive in telling us
what you think. Okay?
DR.
GIUDICE: Thank you for that
clarification. Dr. Slaughter, you have a
comment?
DR.
SLAUGHTER: May I also just say we would
like, also, that we will have access to you.
So we may seek your input further after this meeting is over. So we would expect that we would have continued
interaction on this.
DR.
GIUDICE: Thank you.
Presentation of Questions and Committee
Discussion
DR.
GIUDICE: The first question is a request
to discuss what enrollment criteria should be used to adequately capture the
population to be studied for ovulation induction and for ART. This is quite a loaded question. There are clearly two groups, the
ovulation-induction group and the ART group, so, perhaps, we can start off with
the OI group bearing in mind the WHO1-WHO2 and also the infertility
population. So there are really three
subgroups within the ovulation-induction group.
So
I open this discussion to the other members of the committee, if someone would
like to begin to discuss the enrollment criteria for OI, initially. Dr. Keefe?
DR.
KEEFE: Rather than answer, I have a
question about the role of the FDA in ensuring sort of the precision of a
study, the generalizability. I think I
alluded to it in my presentation. A few
treatments in medicine today are applied to such a narrow band of the American
population which is changing over time.
But is it the role of the FDA or does the FDA feel responsible for
questioning that?
For
example, I work in a state where my patients include sheet-metal workers as
well as heiresses from Newport, and I see big variations in the way they
metabolize drug, the way they--they may be smoking or not, not telling you,
body-mass index, weight. So there are
enormous things that are tied, in part, to socioeconomic class, ethnic
background and racial background.
Should
you be concerned that the studies are coming out looking at investment bankers
from Manhattan and how they are going to apply to my patient population? Is there part of your deal or not? Do you care?
DR.
SHAMES: That is part of our deal. We do a lot to try to make sure that the
clinical-trial results are generalizable to the general population. However, you can imagine that is very, very
difficult. And so we do the best we can
to make sure that the clinical-trial population reflects the general population
or the population that is going to be using the drug. But it is something that we cannot do
perfectly.
DR.
GIUDICE: Dr. Emerson?
DR.
EMERSON: This is just a question to cure
my ignorance--well, not cure it, but alleviate it. Ovulation induction, is that term ever used
for the idea of induction of menses in amenorrheic women and would this
indication be covered by that?
DR.
GIUDICE: Other colleagues are certainly
welcome to respond. For women who are
not interested in fertility who are anovulatory, there are other ways to either
protect the endometrium or to promote monthly withdrawal bleeds, for instance,
with oral contraceptives.
However, to promote a monthly bleed,
one would not use gonadotropins or antiestrogens, for instance.
DR.
EMERSON: So it is just that indication
would not cover this.
DR.
GIUDICE: No. I assume the rest of the committee agrees
with this? Thank you.
DR.
SLAUGHTER: Also, from the FDA
standpoint, we do have indications for treatment of amenorrhea so this would
not cover that. This is strictly for
individuals seeking to become pregnant.
DR.
GIUDICE: Thank you. I hope all these questions have not had the
major purpose of trying to avoid answering the first question. But I think it is time. So who would like to begin the
discussion? Dr. Emerson?
DR.
EMERSON: So, on those grounds, then, it
is very, very difficult for me to completely separate all of these questions
and answer only one. So I do need to
point out that I am going to be answering this question with an eye towards
what I am also going to recommend as endpoints and that a concept of a
noninferiority trial would be very, very appropriate in my mind for an endpoint
of pregnancy.
What
that means is that when we are enrolling patients, we have to make certain that
we have a patient population that is comparable to the ones in which we made
the judgment that the existing active comparators are efficacious. So it obviously wouldn't do to be comparing a
new therapy of ovulation induction in a population of women who are normal
ovulatory. It is an idea that we have to
apply some standards to say what is the level of infertility when we are trying
to do ovulation induction in hypo-ovulatory women.
If
we are trying to do ovulation induction or hyperovulation induction in, for
instance, egg donors or the normal ovulatory women, then it is important that
we understand exactly what that background is and that the active comparator is
working in that population, that we aren't ending up just testing the new
therapy against something that is really acting as placebo.
So
that would be--my most major criterion is how do you define the population to
make certain that your comparison group
is really gaining benefit from the treatment that it is on rather than it is
just what they would be having otherwise.
DR.
GIUDICE: Thank you. That is very well taken. Dr. Rice?
DR.
RICE: I agree. I really do think that when you look at the
differences between ovulation in patients who are presented for ovulation
induction and what input you would use, that is typically different for us than
a patient presenting for ART. I think it
is very important for us to recognize that the criteria we set for a drug to be
able to induce ovulation would probably be appropriate looking at a population
who has hypo-ovulation.
Some
of our WHO criteria take that into consideration. Again, that population base is typically
going to be different than an ART population who generally may--a large percent
of those patients are already ovulatory and we are trying to "superovulate"
them.
So
I think that, when we look at this, we have to be cognizant of what our
endpoint is. If it is a patient who
doesn't ovulate, then, clearly, getting her to the point where she ovulates
puts her on the same basis as that normally ovulatory person which is different
than that person who is presenting for ART or IVF who ovulates but you want to
increase your number of options when it comes down to the number of eggs you
want to be able to--particularly be able to select that one out that probably
is going to go on to be a pregnancy.
DR.
GIUDICE: Okay. I think I am hearing basically the same
thing. So, for WHO, we can either begin
with WHO1, WHO2, or dive right into the infertility normal ovulatory
group. Does someone want to begin,
because right now these are the criteria for enrollment which is what the first
discussion is on. Does someone want to
address standard of care in terms of what we do in the office when someone
walks in with infertility? Dr. Toner,
are you going to rise to the occasion here?
DR.
TONER: I guess, for the anovulatory,
apparently anovulatory, patients, we would want to know that that, in fact, is
the case by measuring basal gonadotropins, by measuring progesterone, and the
hypothalamic style patient will have very low FSH and very low LH at any old
time you choose to measure and, in conjunction with a history of irregular
absent menses, could probably be diagnostic of that circumstance.
Progestin
withdrawal? I guess you could consider
it. Absence of bleeding after progestin
is another hallmark of that circumstance.
DR.
GIUDICE: And after ruling out any
organic causes, hypothalamic or pituitary.
So that would be more in the exclusion criteria. Yes?
DR.
EMERSON: We would also need to talk
about the criteria for infertility, how do we document the time period that the
couple has been infertile with a way that we do that because, once again, we
are dealing with active comparators that have not truly been tried head-to-head
against placebo.
So
we don't know what those rates are.
We are going to have to go on an
understanding of what that is and our best guess so the best numbers that I
gleaned from the background materials and what we have talked today is that a
fertile couple, we would expect a roughly 20 percent fecundity rate and
that, after a year of infertility, it is something down to 11 percent.
Yet,
we saw roughly 20 percent in the previously approved trial. So we are talking about roughly a
10 percent difference in the fecundity rate. As you are now going to look ahead trying to
guess what difference we would tolerate in an active-comparator trial and still
believe that we would have had efficacy against placebo, because that is sort
of what a noninferiority or some one-sided equivalence trial is trying to do, is
trying to guess what a placebo trial would have done to make certain that, when
we go out there and say, this does work for ovulation induction and going on
into pregnancy, we would get that.
So,
the mix of patients, if it is down to 11 percent after one year
infertility, if it is down to, I can't remember the numbers, 4 percent after
two years of infertility or so on, that is going to be the criterion that we
are using to base this.
So
we want to make certain that, as we compare the active comparator, they haven't
snuck in a group that would actually have a lower rate or a higher rate, that
we are accepting enough worse behavior that is actually taking us down to the
level that it is an ineffective treatment.
DR.
TONER: Could I address that?
DR.
GIUDICE: Dr. Toner.
DR.
TONER: As a practical matter, though, if
the clinician has a very confident idea that this is an anovulatory patient, we
are not comfortable waiting a year, any clock to run. If we make the diagnosis, we want to treat
now. So that interval, for this type of
patient, isn't going to be appropriate and we won't get anyone enrolled.
DR.
GIUDICE: Thank you. Dr. Keefe and then Dr. Layman?
DR.
KEEFE: I was going to say the same
thing, that we are trying to establish the diagnosis of an anovulatory
infertility, the first is the diagnosis of infertility and I agree with Dr.
Toner that you are not going to wait a year if somebody is documented to be
anovulatory.
But
the documentation of anovulation, I think in the spirit of keeping things
generic and broad, I would say clinically useful methods of diagnosis of
anovulation and they would include periodic progesterone measurement, LH surge
detection, presence of amenorrhea and the absence of uterine factor.
As
well, as was already mentioned, but just to include the importance of ruling
other causes of anovulation such as hypothyroidism and hyperprolactinemia as
well as primary ovarian failure.
DR.
GIUDICE: Dr. Layman?
DR.
LAYMAN: I was going to reiterate some of
that as well. I think you need to
exclude hyperprolactinemia in both Group 1 and Group 2. If somebody is amenorrheic and you think they
have Group 1, then I think they really need a progesterone withdrawal to show
that they are hypoestrogenic so that they don't bleed. Otherwise, it doesn't fit into
hypogonadotropic hypogonadism.
Gonadotropins can be low or normal in the face of that. Depending on what assay you use, that is
going to make a difference whereas, in the other group, I think one thing we
have to think about is the prevalence of both disorders. Group 2 is much more common so that I think
the guidelines for Group 2 may--for Group 1, you don't want to maybe be quite
as stringent as Group 2 or you are just not going to get enough patients.
DR.
GIUDICE: Yes?
DR.
LEWIS: Also, although it may go counter
to what you see in clinical practice, I think that the patients in either Group
1 or Group 2 or the ART population, for that matter, should pretty much be of
relatively normal body-mass index.
We
know that extremes of obesity are quite common, or even just garden variety
obesity, are quite common in the general population today but I think it is up
to the clinician to adjust for that.
When you are designing a clinical trial, I think it is useful to have
patients just be relatively body-mass-index normal to glean the cleanest
information possible from the study.
DR.
GIUDICE: Any comments about BMI for WHO2
type patients?
DR.
KEEFE: I have a question. I know what you are getting at, like try to
reduce the variance and you would be able to better control the study, but it
seems to me that that might lose some of the clinical value of the study. Those are precisely the ones that are the
toughest, and so you get this beautiful result in the study.
As
you move into the clinic, you might bump up against some problems with that.
DR.
LEWIS: Well, of course. But, in any clinical trial, it is going to be
quite different. What you see published
in the literature and what it boils down to in clinical practice, we all know
that. That is the practice of medicine. If you start out with a most difficult
population, to design your clinical trial, you may mask an effect that might
otherwise be quite useful to the rest of the population. So, I think if you start with a more ideal
population and then try to apply it, see how far you can push it one way or the
other, you are going to get a better result.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I think we know a lot more
information about the impact of BMI on ovulation. So that may be something that you could
consider for a stratification based on BMI.
That is one of the things that I think would be very critical. If you have a product that is coming out
looking an anovulatory patients that you want to stratify it, not just on age,
et cetera, but you also want to consider BMI because I think that we all have
instances where we have seen patients who lose weight who then become
ovulatory. That is the only thing that
they have really changed.
So
I think BMI could be used as a stratification.
DR.
KEEFE: I have a comment about the use of
the progesterone-withdrawal test as an inclusion criteria. While clearly it is useful to test the
integrity of the uterine tract and the vagina, you can have a negative
progesterone withdrawal and still have an ovulation. It is just listed as sort of one sentence in
Spiroff. But I have found it very
frequently, patients that are hyperandrogenic will not withdraw.
So
you might have to give them steroid, presumably to decidualize their
endometrium from the high androgens. It
is not clear exactly why but it is very common that you will see that they will
have a negative progesterone withdrawal and yet they are actually
hyperestrogenic relatively and they have a completely intact tract.
So,
rather than say progesterone withdrawal, maybe a steroid withdrawal which would
include the next step where you would probably give them estrogen and then
progesterone.
DR.
GIUDICE: Dr. Layman and then Dr. Rice.
DR.
LAYMAN: I agree that some
hyperandrogenic women won't bleed. But I
don't see adding estrogen, how that will help, actually. But I think the way you get around that, and
it is difficult in some PCOS women, to tell from hypogonadotropic hypogonadism
whereas, if you look at hyperandrogenism, it may help you differentiate since
hypogonadotropic patients usually have low testosterone. So that might be a way.
But
I agree. It is not black and white for
the progesterone withdrawal. And it
should be like a good bleed. It
shouldn't just be spotting.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I would just caution that the ASRP
Practice Guideline is probably going to be coming out very soon with the
recommendation to remove progesterone withdrawal. So just before--when you look at the draft
document, make sure that the guidelines haven't changed and the utilization of
progesterone withdrawal.
DR.
GIUDICE: Have they substituted something
else for it?
DR.
RICE: No. Just making a comment.
DR.
GIUDICE: Thank you. Dr. Emmi?
DR.
EMMI: In light of what is being said
about hyperandrogenicity and lack of withdrawal, frequently those patients will
have fecund endometriums on ultrasound and that is a good way of
differentiating sometimes. If somebody
is hypoestrogenic, they don't have a lot lining as opposed to people who have
20 millimeters of lining on ultrasound.
So that may be a point to look at.
DR.
GIUDICE: This is an interesting issue,
whether or not ultrasound should be part of the enrollment criteria, whether it
is for hypothalamic or Type 1 or for Type 2.
Then, in looking for age and ovarian reserve, whether that is part of
it.
So
we can get into the infertility side in just a moment, but I think also we do
need to consider the cost perspective of putting ultrasounds in clinical trials
which can be quite costly, but certainly is something that can be recommended. So what does the group think in terms of
ultrasound used adjunctively for entry criteria?
DR.
EMMI: I don't necessarily think it would
be necessary in all patients. It depends
on what parameter you use to decide is a patient in Group 1 or Group 2. I mean, if you are going to use estrogen
withdrawal, progesterone-withdrawal bleed, then, if they don't bleed, you are
either going to look for hyperandrogenicity or you are going to look for some
other reason why they haven't withdrawn and, at that point, perhaps, adding it
might keep the cost down.
DR.
GIUDICE: Dr. Crockett?
DR.
CROCKETT: Yes. I just wanted to throw in my two cents about
this whole question of the anovulatory versus the infertility patients in the
enrollment. I think, as a group, when we
are looking at making guidelines, the less specific we make the guidelines, the
more applicable they may be down the line.
If
we are looking specifically at anovulatory women that have, by definition,
whatever definition we come to, anovulation, we shouldn't include things that
pertain to other parts of the fertility process in making inclusion criteria. For instance, if we start talking about
endometrial lining, that is not necessarily an indicator of ovulatory function
or dysfunction. It is more a function of
fertility and the ability to implant and carry the pregnancy.
So
I would rather us kind of back up and say let's look specifically at ovulatory
and anovulatory women for what they are and leave the whole fertility side out
of it.
DR.
GIUDICE: Okay. Dr. Lewis?
DR.
LEWIS: Actually, I think the reason, the
rationale, for bringing up endometrium was as a reflection of estrogenicity;
that is, the endometrium would be thicker if there has been ongoing estrogen
production thus separating Type 1 from Type 2.
At least, I think that is why it was brought up.
But
the only--well, another possible complication of using ultrasound to
differentiate between the two is that you can see a multifollicular pattern in
both types and so some centers, particularly in Europe, like to use ultrasound
to diagnose polycystic-ovary syndrome.
But
that appearance can also be seen in Type 1 patients, especially if they are
younger. So it is, I think, a little
problematic to use ultrasound as a primary criteria. But, obviously, you have to use some sort of
criteria to define that the patient has low gonadotropins and low
estrogenicity. Maybe you could make it
either/or, either a negative progesterone withdrawal or thin endometrium with a
low circulating estradiol level. That
might be an option.
DR.
GIUDICE: Okay. Yes; Dr. Keefe?
DR.
KEEFE: This is really halfway through
the first question. Maybe we should just
wrap it up and say something like the committee recommends that enrollment
criteria include the presence of oligomenorrhea and/or amenorrhea with some
evidence of lack of ovulation on the basis of blood tests, progesterone,
urinary tests, LH surge or other methods which could include ultrasound.
DR.
GIUDICE: Thank you. Also, for Type 2 patients, there was recently
a nonconsensus consensus conference in Rotterdam and I think, and you are
absolutely right, we are only halfway through the first question, the whole
Type 2 story is, again, very, very complicated.
For us to put together today guidelines, I think, actually would
probably consume the rest of the afternoon.
So
I would like to know from the group if, perhaps, looking at the NIH guidelines
in terms of definition of PCOS which, then, could be applied to enrollment
criteria, if you think that would suffice for the document.
DR.
KEEFE: Yes. Sounds good.
DR.
GIUDICE: Okay. Then, moving right along; No. 2, should
enrollment criteria be stratified by age for--I'm sorry; we didn't finish ART
inclusion. Let's go back to that. I thought we were out of No. 1.
DR.
KEEFE: We are only a third of the way
through the first question. I forgot.
DR.
GIUDICE: No. We have done WHO1 and we have punted on WHO2.
DR.
KEEFE: Right.
DR.
GIUDICE: And now for ovulation induction
for infertility, the enrollment criteria for that. This brings up many, many issues. If you have someone who is 42, you are
probably not going to be doing this, or don't want them in a study for looking
at a gonadotropin product.
Also,
if you have--there is a whole series of things and people practice very
differently. The criteria that are
normally used when a couple comes in after twelve months, and, Dr. Emerson,
this is to address your question about the definition of infertility, I think
it is pretty standard that one takes the definition of twelve or more months of
unprotected intercourse without a pregnancy, but then the age issue comes into
it and whether--if someone comes in at the age of 40, one doesn't usually ask
her to go home and come back in a year and then we'll talk about pregnancy and
fertility.
So,
we do need to discuss the issue of--and this will, also, then, have some
relevance for the second question. But,
going to the first, for ovulation induction for infertility, I would like for
the committee to address what types of enrollment criteria they think are
appropriate for the FDA to have in trials.
Dr. Layman?
DR.
LAYMAN: To start it, I would think you
would have to pick some age group that would be agreeable to everybody, and I
will throw out 25 to 34, but some age group that is reasonable would be one
thing. The other would be maybe
potentially eliminate ICSI with a severe male factor, to take ICSI out of it so
that you are looking at fresh-cycle, first-cycle, patients.
But
I would think other diagnoses would be reasonable to consider. I mean, I don't think male factor would be
unreasonable. But if you start putting
in ICSI with it, then you are getting in more variables.
DR.
KEEFE: I am really uncomfortable with
essentially disenfranchising a huge population, a growing population, of the
infertile population. I don't think it
is appropriate to, a priori, recommend that a certain age group be
studied. It may well be that, in the
future, pharmaceutical companies find it to their advantage to target certain
drug regimens. I mean, from a financial
standpoint, that is where the money is; right?
That is where the growth is. That
is where our demographics are pushing us.
So
you may want to, for a number of reasons, if you are trying to document the
efficacy of ovulation, but, if we are looking at the clinical endpoint, I don't
think we should box out this growing population right up front and recommend
that they be excluded.
I
would say that we should tailor the inclusion criteria according to age and
that we should include an age-specific diagnosis of infertility, six months, 35
and older, twelve months, younger than 35, which is sort of the standard.
DR.
GIUDICE: Dr. Emerson and then Dr. Emmi.
DR.
EMERSON: I think this idea that there
would be other issues that come up after the therapy and all of the
complicating things that will have an effect on the event rate, but it is
randomized trial. I don't know of a
disease that doesn't have ancillary treatments following the interventional
treatment.
So,
while you have to give thought to whether your treatment might cause people to
change the ancillary treatments and so on, it is not an issue. This just occurs in every single trial and,
by randomized, it ought to be equal if it is not caused by the treatment.
DR.
GIUDICE: Dr. Lewis?
DR.
LEWIS: I think that, certainly, a
clinical definition of one year of infertility is widely accepted and that is
fine. But I think there ought to be
exceptions for ART if the infertility is due to a tubal factor. If you have occluded fallopian tubes, there
is no reason to wait one year.
So
I think you should have evidence of a normal uterus to be in the clinical trial
and some documentation about the fallopian tubes. Some of the trials, I know, that have been
done in Europe, have excluded patients with hydrosalpinges because that can
have an impact on the trial and that might be something that is reasonable to
exclude.
You
could exclude patients with ICSI. But,
in the United States, about 60 percent of--at least 50 percent of IVF cycles
include ICSI. Even if the patient
doesn't have proven fertilization, a lot of centers will recommend ICSI on at
least some of the eggs.
So,
rather than exclude all ICSI, you might set some limits on it, ICSI with testicular
sperm, perhaps. ICSI in particular
cases--maybe Dr. Lipshultz has some input here to give, but I don't think you
would want to exclude all ICSI because I think that would limit the population
too much.
I
agree that you have to have age limits and maybe 34 is a little Draconian, but
maybe 38, under 38? And I don't think
25--I think you could go younger than 25.
There are some patients that would be reasonable to treat.
DR.
GIUDICE: Dr. Emmi and then Dr. Rice.
DR.
EMMI: I was going to make one of the
points that she made which is that something like 60 percent of the cycles in
this country are ICSI at this point so it is difficult to factor them out and
why ICSI is being done in those cases.
But
I think, with the age matter, that may be something that might be nice to
stratify. I think--I mean, if you look
at one of the studies that Dr. Toner was talking about with decreased
follicular depletion over time, I think that the cutoff there is about 37 where
you see a really rapid decline in the number of eggs in the ovary.
Maybe
you could make that, 37 and above--I don't necessarily think that you have to
stop at 38. I think you could go to 42
and just look at that group as a separate group.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: It is difficult for me to set up
enrollment criteria if I haven't established what my endpoint is that I am
going to evaluate. If I am going to
evaluate number of oocytes for a different gonadotropin, then I pretty much
know that, regardless of age, I can give probably most women enough medication
and get equal number of oocytes. But if
I am going to set up fertilization as my endpoint, then I would set my age of
enrollment differently if I wanted to say whether Product A was better than
Product B if I wanted to be able to answer that question.
So
you kind of got to say what your endpoint is.
I think Dr. Toner showed us some data that says you can get a
42-year-old to act just like a 32-year-old when we are looking at the number of
oocytes that are retrieved. But it really
comes down to the bottom line, a 42-year-old doesn't get to take home a baby as
often as a 32-year-old.
So
there are other confounders that come in there, but there are some variables
that we may not have control over. So I
kind of have to know what my endpoint is before I can say what my inclusion
criteria are going to be on several of these issues.
DR.
GIUDICE: I think this is where we see
one size does not fit all because, if you don't know what your goal is, it is
very hard to set up the criteria.
The
other issue we may want to discuss, and perhaps not belabor the point, but is
age really the issue that we want to talk about or is it ovarian reserve
measured by other means, either ultrasound, complement of small antral
follicles, ovarian volume, Clomid-challenge test, Day-3 FSH and estradiol. There is a whole series of things.
These,
again, I think one could put in, and certainly the committee should discuss
this, but as we advise the FDA, these are all the things that we deal with
clinically that, as clinicians, we are evaluating the performance of the
ovaries in response to these medications.
Dr.
Toner?
DR.
TONER: I think, in that regard, you
might want to set up sort of a stratification where you define upper limit of
normal and then you define a borderline range, but then kind of a
"no-go" range as well, for the purposes of studies.
So,
for instance, on the issue of age, you might say that there is a group that is
under 38. Then there is a group that is
from 38 to 41, 42. But we are never
going to study people past 42 because it is so futile.
On
the ovarian-reserve side of the equation, you might say, we are going to
consider normal, basal FSH under 10. 10
to 15 is the ambiguous area where we expect some diminished reserve but it may
be okay. But we are not going to enroll
anyone with an FSH of 16 or better. You
know what I am saying? So there may be
some advantage to demarcating where things start to get a little tough and
where things become hopeless and break them out that way.
DR.
KEEFE: Can I comment?
DR.
GIUDICE: Dr. Keefe and then Dr.
Crockett.
DR.
KEEFE: I don't think the FDA--the
advisory committee should be in the business of lowering our sites as a
field. I mean, it is clear that there
hasn't been a lot of progress in this area, but it is going to be the
pharmaceutical companies' problem if they don't account for these. Their bias is going to be already to exclude
these patients.
So
I don't see the advantage. I mean, if
you are trying to design the perfect study to show an effect, yeah; you,
yourself, as an individual designing the study, would clearly want to narrow
the variance by selecting a very carefully chosen population.
But
we, as the advisory committee, I don't think, should constrain the field by
blocking that out. Let's say I move
forward five years and I have come up with a new way of identifying that subset
of 5 or 10 percent of the 42-year-olds who can get pregnant. Oh, but the FDA, though, has this thing where
you have to be under 38 or 37. You know,
that is not encouraged.
So,
while you might want to control for that, I think what we want to do is cast a
broad net for this.
DR.
GIUDICE: Dr. Crockett and then Dr.
Lewis.
DR.
CROCKETT: What he said. The other thing I had to add to that is that
I think, once again, we are getting too narrow.
What we couldn't do ten years ago, now we are talking about designing
studies around today and, in ten more years, we are going to have so much more
technology available that, for us to be talking about what we want as
stratification for endpoints and inclusion criteria I don't, as a governing
body, we should be doing that.
DR.
GIUDICE: Thank you. Dr. Lewis?
DR.
LEWIS: I don't think we are saying what
population needs to be treated for infertility.
That is not the mission of the committee or the mission of the FDA. It is simply to talk about what criteria
would be useful in determining whether a drug is effective and safe or
not. It doesn't mean that we are saying
that this patient will never get pregnant.
It doesn't have anything to do with that or with saying what the future
of the field is going to be. It is
simply to try to help the FDA come up with criteria that they can use with
industry to design a study to say whether the drug works or not.
I
think if you start with a population where you might reasonably expect to see a
better pregnancy rate, where it has been shown that a good pregnancy rate
exists now, then you will go further.
The trials will be more economical to devise. The drugs will get to market sooner so that
we can use them in new populations who are more difficult to treat.
So
I think if you look at it that way, it, perhaps, might have some utility.
DR.
GIUDICE: Depending on the endpoint.
DR.
LEWIS: Yes.
DR.
GIUDICE: Dr. Crockett?
DR.
CROCKETT: With all due respect, I
disagree with you a little bit on this.
I think, from a standpoint of a regulatory agency, if we say to a drug
company, we have a guidance that you can't enroll somebody over the age of 42
because it is futile, that we are going to severely limit the free market and
the development of that research.
I
would rather not see that kind of cap put on either for ovarian reserve or
age. I think it is too restrictive.
DR.
GIUDICE: Dr. Hager and then Dr. Dickey.
DR.
HAGER: It would seem to me that what we
are saying is not to exclude but to stratify and that way those populations are
included but the data are recorded accordingly.
So I don't think--I would agree that we would not want to exclude them
but we certainly would want to stratify those populations.
DR.
GIUDICE: Thank you. Dr. Dickey?
DR.
DICKEY: I think David probably said it
very well. If we stratify, you can
always add new populations on either end or, for that matter, new enrollment
groups. What you want to avoid, I think,
is comparing apples and oranges. So, by
stratifying, you can begin to do that and still push the edges of science as
that opportunity comes along.
DR.
GIUDICE: Thank you. Dr. Rice?
DR.
RICE: I think, though, you capture all
of this stratification if you begin to change your endpoint because, right now,
you have it where all you have to do is show follicular development. All of them showed that pretty evenly across
the board.
If
you take that 32-year-old and that 42-year-old and you say, my endpoint has to
be fertilization, or it has to be live birth rate, in order to get said
whatever indication they are going after, the stratification, then, begins and
it really starts to really compare the gonadotropin compared to each other and
compared to "placebo."
So
I think you capture it. You keep your
inclusion broad. And then you capture it
by looking at your endpoints.
DR.
GIUDICE: Dr. Hager?
DR.
HAGER: Could we go to Question 8 and
come back? I mean, it keeps coming up.
DR.
GIUDICE: Question 8.
DR.
SHAMES: Sure.
DR.
GIUDICE: I think we have pretty much
completed No. 1 because the ART piece, from what I have heard, is very tightly
connected to the infertility, ovulation induction and infertility. So we have done No. 1. And we can go to No. 8. We have also done No. 2. Maybe we can just go down some of the
questions, here.
Should
we stratify for use of adjunct procedures such as donor oocyte or ICSI.
DR.
LAYMAN: May I?
DR.
GIUDICE: Yes.
DR.
LAYMAN: Just in terms of ICSI, I mean
ICSI is not one thing. ICSI is many
different indications and to have one category of ICSI is going to be asking
for trouble because you are not going to get the same rates if you do ICSI in a
program who does everybody because they are afraid of missing a cycle and
opposed to another one who does testicular extraction because they have a lot
of male factor.
So
ICSI has to be subdivided or else--you know, when you are collecting data, or
else you are going to lose the meaning of the outcome.
DR.
GIUDICE: So that would be stratified,
also, then.
DR.
LAYMAN: Substratified.
DR.
GIUDICE: Or substratified; yes.
DR.
LAYMAN: But the answer would be yes to
No. 3.
DR.
GIUDICE: Okay. Let me ask the FDA members if we need a
formal vote on any of these. No. 1, we
can't vote on. I think there is pretty
much consensus, at least from the nods around the table, about criteria should
be stratified by age and stratifying use of adjunct procedures, and then
substratifying for ICSI.
Now,
this is a very interesting question; should studies be blinded or not and, if
blinded, discuss the merits of blinding the assessor, the patient or both. Dr. Emmi?
DR.
EMMI: I just wanted to make one comment
about Question 2 before we went on.
Since, when we discussed ovulation induction, we actually discussed the
difference in anovulators whether they were criteria 1 or 2. Should that be for ART as well?
DR.
GIUDICE: Well, how about going around
the table or at least--how about if you rephrase what you would like for people
to either agree or disagree with.
DR.
EMMI: Well, what I propose is that there
is a difference in response in PCO patients and IVF and differences in LH and
whatever your belief is whether it affects the endometrial development or the
number of follicles and should they be stratified out as a separate group when
you are looking at ART.
DR.
GIUDICE: I see nods.
DR.
HAGER: I thought, as we were talking
about ART, that we were talking about those divisions anyway, tubal factor,
PCO, et cetera. Was that not the
consensus?
DR.
GIUDICE: I don't think we actually made
it clear. But we should make it
clear. The indications for ART,
certainly, are several. One, with the
PCO patient, in particular, is sort of an interesting situation, those who
fail, essentially, monofollicular development or have had one or several
follicles without a pregnancy who then may progress to ART is a very different
population than the woman who walks in at the age of 39 for unexplained
infertility where you start gonadotropins and then you go to ART.
But
it seems that the categories would stratify out. Or you can put them in. It depends on what the objective of the study
is. But we have talked about male
factor, anovulators and we didn't really discuss unexplained. But there is not really too much additional
information that we would need to discuss unless someone has a burning issue.
DR.
KEEFE: One other diagnosis that may bear
or may merit stratification would be severe endometriosis because there is
growing evidence from split-donor cycles that the donor, if she has severe
endometriosis, confers a reduced probability of success on the recipient. Meta-analyses have, I think, shown that there
seems to be a fairly consistently lower pregnancy rate but only in severe
endometriosis, as well as a low ovarian reserve. They start to resemble older patients.
DR.
GIUDICE: Dr. Brzyski?
DR.
BRZYSKI: In unexplained category, are we
assuming that, as part of the screening for enrollment, that individuals that
have some measure of ovarian reserve, because it is a fairly good likelihood
that there could be impaired ovarian reserve in individuals with otherwise
unexplained--you know, patent tubes, normal male, ovulatory. There is still a pretty high yield of impaired
ovarian reserve in that population.
So
we are assuming that, in that unexplained, that those would be screened and
identified and stratified by that? Is
that a true statement?
DR.
GIUDICE: What does the committee think?
DR.
TONER: As the advocate of
ovarian-reserve screening, I think yes.
You honestly just need to do it.
I mean, you do a semen analysis to detect how many sperm are there. You have got no other way to assess how many
eggs are there without looking, either in the blood or on ultrasound.
DR.
KEEFE: Can I answer? I agree completely with what Jim said. We would think of ovarian reserve as parallel
to age. It is sort of like reproductive
age. And, as Jim showed, there is an
independent predictive value for each separately and, together, they interact. So, I would recommend we treat ovarian
reserve like age, similarly. So even
with the outcome of ICSI, in pure male factor, you can see a component of
ovarian reserve.
The
question is how do you measure it because our radioimmunoassays vary from
center to center. So you have to have
either a central lab or some standardized method. There are also problems of the cycle
dependency of it.
There
will be new ovarian-reserve markers coming out.
Bularian-inhibiting substance has been recommended by Themin as a very
useful cycle-independent marker secreted in the pre-antral phase of follicle
development. So I think there will be,
down the line, additional markers of ovarian reserve that will have to be
considered.
DR.
SLAUGHTER: Just a comment. We do typically request these studies when
they do these assays to be done in a central lab so that would be included.
DR.
GIUDICE: Thank you. Dr. Layman?
DR.
LAYMAN: I just have a statistical
question to the statisticians here. If
we get too many groups, is that going to reduce our power? I mean, that is why I was only saying a
certain group. But, you guys have to be
the people on that issue.
DR.
EMERSON: So I am completely unable to
judge any of the criteria that you have just named of what they mean medically,
but, again, the overarching principles here are in doing clinical trials it
that the enrollment criteria should be as close as they possibly can be to the
population that you are eventually going to use this in.
That
sometimes means that people that you don't really think the treatment will be
all that beneficial in but it is going to be extrapolated to that population,
you need to see the safety data. So you
sometimes go ahead and include those patients but then say they are not really
going to be in our efficacy population.
We are just going to make certain that it is still safe.
The
other criterion is when you have an active comparator, what I spoke to at the
very first. You need to make certain
that it really is an active comparator and it is not placebo as you are setting
those margins.
Then,
in the stratification question, the reason why we stratify is, first and
foremost, to gain precision. But there
comes some point that, if you are doing a multicenter trial, you can't do too
many levels of stratification. If the
trial is relatively large, you don't need to stratify and you can still get the
precision by adjusting for it. It
sometimes takes an argument to get it through the FDA, but that is what should
be being done in those instances.
The
other aspect is scientific credibility of the results. If, by rights, by what we mean by statistics,
you don't have to stratify on anything.
But, if somebody sees that a large imbalance occurred on the trial, they
aren't going to trust the trial. So
those variables that are the most predictive but don't go to too many cells;
just choose those that are.
From
what I have heard, mainly, it is this aging aspect, be it ovarian reserve or
age as a surrogate for ovarian reserve, and then the various adjunct
procedures, the indications for why we are going to that sound like the largest
ones.
And
then you always have the site-specific issues that you want to do the
stratification within site. That is
going to be pretty much maxed out.
Really, even if you are going to a thousand-patient trial, you don't
want to stratify on much more than those things.
That
is my impression from what I have been hearing.
As suggested, I probably wouldn't stratify on much more than that.
DR.
GIUDICE: Okay. Thank you.
Perhaps we can now go to Question No. 4 regarding blinding or not. Yes; Dr. Emerson?
DR.
EMERSON: Blinding; I am a statistician
so you need a larger sample size and you need to blind yourself. But the issue here that I think is greatest
is we have already heard aspects of the doctor effect in getting the follicles,
that judgment goes into that concept.
Obviously, if they know what the treatment is and, well, of course, this
treatment produces more follicles than the other and, therefore, we will sample
all of those more follicles that we see here.
That
is an issue. Also, the other thing that
I worry about is canceling a cycle, to decide not to go with the
stimulation. So I can't imagine many
things that the patient would--I think, otherwise, we are only talking about
fairly objective criteria, so the patient we are not worrying as much
about. But it is all the investigator,
the clinician, that I would worry about.
DR.
GIUDICE: Dr. Emmi?
DR.
EMMI: I wanted to know why cancellation
is such an issue.
DR.
EMERSON: We are back to my "intent
to cheat." If I have a really good
therapy that I am sure works, but I start seeing a patient that it doesn't look
like it works, or that I am not liking the way it goes, well, I will just not
try that patient very much more.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I think we also have to remember
that, particularly if we were looking at embryo quality as an endpoint, that we
still don't have the most objective means for grading embryos. So it is clear that we must have our
embryologists who are blinded as well so that we have some objective
information that will come out of that if we are going to use embryology or
embryo development as a criteria.
DR.
GIUDICE: That is a very good point. Other discussion? Yes?
DR.
EMMI: I think we are back to it is
getting very complicated because not every institution uses the same criteria
even for judging embryos. You know, then
you would have to restrict, also--if you had somebody who wanted to cancel, you
would have to have cancellation criteria.
I mean, I just don't know how you can--
DR.
RICE: That is the benefit of blinding,
that you can take care of some of these subjective issues.
DR.
GIUDICE: Dr. Hager and then Dr. Keefe.
DR.
HAGER: The only reason not to
double-blind the trial, in my opinion, would be if you had a placebo arm
because then there would be a distinct difference. If you did not have a placebo arm, would it
not be more efficacious to double-blind rather than single-blind?
DR.
GIUDICE: Comments?
DR.
EMERSON: I guess my response would be
that just purely logistically I think it is easier to maintain a blind from the
patient and not the physician than vice versa.
So I don't see any reason not to keep the patient blind in that
instance, but it is just the assessor that I am most worried about.
DR.
KEEFE: Okay. Are we ready to move onto question No.
5? Here we come now to the placebo and
active-control arms in the studies. If
an active control is used, discuss how you would define the noninferiority
margin. Dr. Hager?
DR.
HAGER: My feeling is that, from an
ethical perspective, it is better to have an active control arm in this
population of individuals.
DR.
GIUDICE: Other comments? Yes?
DR.
TULMAN: Just from the person you are
trying to enroll is given a choice, a known choice, between a placebo or the
new investigational drug, are you likely to get anybody to consent to be in
it? So, from a very real patient
enrollment point of view, if you are not offering a treatment that at least is
one standard of care versus the new point, you are going to have a trial that
will not get off the ground.
DR.
GIUDICE: That is a good point. Dr. Brzyski?
DR.
BRZYSKI: To my experience with clinical
trials, or not even in clinical trials, I think patients tend to believe in
technology and the newest technology and so that would be one reason to blind
even in an active control arm, that patients may cancel themselves if they are
randomized to the traditional therapy as opposed to the new therapy which
everyone believes will be the better therapy.
Otherwise, why would we be studying it; right? So, it just again supports the idea of
blinding the patient.
DR.
GIUDICE: Thank you. One more comment? Yes, Dr. Keefe?
DR.
KEEFE: I would also support not using
placebo and, instead, using a treated control group. We now have published literature showing the
baseline fertility in untreated patients with unexplained infertility and
recently a paper came out of Belgium where they looked at the spontaneous
pregnancy rate after one failed cycle of ICSI.
So these were people shown to have significant male factor and then,
subsequently, there was a very low spontaneous pregnancy rate. Occasionally, people would get pregnant.
So
we have pretty good evidence that the untreated group, at least from
observational studies, don't do well. So
I agree; it is a little bit problematic ethically to deprive treatment through
placebo. So control should include
treatment.
DR.
GIUDICE: Okay. Thank you.
No. 6 is, discuss the advantages and disadvantages of single versus
multiple treatment cycles. Dr. Emerson?
DR.
EMERSON: There was a second part to
Question 5.
DR.
GIUDICE: Oh, sorry. You're right.
DR.
EMERSON: Which is how--using the active control,
how do you use a noninferiority margin.
The issue here, and I already alluded to this earlier and I am pretty
much going to say the same thing but I will try to say it quickly, therefore,
is that if we imagine that this 20 percent rate--I mean, these are the
criteria to use, whether we use other data to come up with this.
But
if we were having a 20 percent fecundity rate in the previous--in what little
data we have from the controlled trials, and if we believe that it should have
been 10 percent or less in an infertile population, the idea is how much of a
decrease will we accept. Making up a
number of roughly a 6 percent decrease or an 8 percent decrease would be
allowing for the idea that you might actually have a mix of patients who were a
couple years out infertile and so that the 10 percent or 11 percent I was
quoting was from the 12-month infertile rate.
So that would still be giving you this margin.
So
then a noninferiority trial is saying, we will feel confident at the end that,
if we declare the new trial noninferior, it is not more than 6 percent
noninferior. So we make a statement like
that with 95 percent confidence. But
something in the 6 percent to 8 percent range would be what I would choose.
The
reason not to go all the way down to the boundary is, again, from the patient
standpoint. Would you want to go on a
clinical trial where you are saying that we are going to tolerate keeping on
testing you on this treatment even when it is substantially below that
level. The criteria of how far I regard
substantially below is the secondary benefits the new treatment may provide,
that there may be less pain involved, less logistical problems, whatever other
conditions might be the secondary endpoints of the trial.
DR.
GIUDICE: Thank you. Dr. Rice?
DR.
RICE: It clearly depends on what you
define as those secondary endpoints. If
I look at the trial now, and my primary endpoint is ovulation induction and
number of oocytes, my secondary endpoint is pregnancy, then I will tolerate a
lot of inferiority dependent on the patient population that I choose. So it depends, again, on those clinical
endpoints.
DR.
GIUDICE: Yes?
DR.
EMERSON: There is no question that I was
giving, as my example, the pregnancy endpoints.
DR.
GIUDICE: Dr. Lewis?
DR.
LEWIS: Yeah; I agree that obviously it
does depend on what your endpoint is.
But also it is going to depend on the patient's age and their diagnosis
and whether you are talking about ART or ovulation induction, even a difference
in pregnancy rates because you are going to--the variance is wider for some.
DR.
GIUDICE: Okay. Dr. Hager?
DR.
HAGER: Just a question. So are we recommending built-in alarms in the
study so that, if we reach a noninferiority level of a certain percent, then
the study will be broken, the code will be broken? Are we recommending that? Is that what I am hearing?
DR.
GIUDICE: Dr. Emerson?
DR.
EMERSON: That is an issue that can be
really separated from--if you decide what your hypotheses are that you want to
test, then, building in a sequential monitoring plan so that, as early as
possible, you identify whether you have met that, can be addressed separately
and almost all IRBs are now demanding that be--FDA and NIH are demanding
that. It is my area of research so I
would be glad to talk to you about it.
DR.
GIUDICE: Perhaps that line of
communication to the FDA can be kept open, then. Dr. Toner?
DR.
TONER: I was going to ask of Dr.
Emerson, I wonder whether--is there any way to standardize or generate a rule
for drug companies to understand what would constitute noninferiority based on
expected percentages of success? I mean,
even if we stick with your pregnancy rate endpoint and, let's say, nowadays,
the pregnancy rate is 50 percent, as the expected, would you still want to
subtract the same absolute number of 6 percent or would you allow it to slip
down to 20?
DR.
EMERSON: Would I want it to stay the
same? Absolutely not. Is there any way that we can give some
guidance? Well, the International
Conference on Harmonization of Clinical Trials has a very long document on
exactly this issue.
Every
case is different and a lot depends upon what the safety concerns are, what the
secondary gains are that you are trying to anticipate. There may well be some people who are willing
to accept a lower fecundity rate which might mean going through more
implantation procedures if they only have to go through one ovulation
procedure.
So,
under those considerations, as you design the trial, you have to consider all
of the side effects, all of the anticipated adverse experiences, the gain that
you might have, as you go through those trials and what--we are back to this
issue of are you going to get people to come on the trial. No trial is very efficient if no one will be
on it, and so you don't do that.
So
it does have to be modified. The issues
have to be broad guidelines but, to the extent that all the data that I have
seen is the table in the background material about what the fecundity rates
are, the longer you have been out of fertile, and then the one comparator trial
that we had from the previously approved thing.
And
then you have to go with that. So it
will change over time as you get more data.
DR.
KEEFE: Can I comment on that?
DR.
GIUDICE: Yes; one short comment.
DR.
KEEFE: I think the discussion should
first focus on those cases in which there is no expected benefit and then could
we then do sort of a power analysis with a two-tailed component in which we are
looking not just whether--you know, what is the size of the sample we would
have to use to find a detrimental effect.
I
think, conventionally, with power analysis, you are looking at sort of 20
percent as a reasonable detection rate.
Is that done? Could you do it
that way where you are essentially--because, otherwise, you are going to be
encouraging companies to make very tiny little studies where there is no
difference found and make the assumption of noninferiority.
DR.
EMERSON: Well, just to give you an idea
because I did just look this up to see what it was. If you went, for instance, with the assuming
that a 20 percent rate was the active effect, and you were willing to go down
to a 14 percent rate and still call that not sufficiently inferior, that you do
that, that would be about a 600 patient, person, study, total, so 300 per arm.
If
you took it down to 12 percent, that would be about 150 or 160 per arm. So those are the sorts of numbers, and that
is--again, in a noninferiority trial, we don't go with that 80 percent power. We really need 97.5 power. We need to say, if it is below our threshold
that we consider acceptable, we want to be 97.5 percent confident that we don't
approve this thing that is inferior. So
our standards have changed. This is the
same thing, if we are using a 95 percent confidence interval to judge this
and that is what those numbers are based on.
DR.
KEEFE: From the standpoint of the
consumer, a lot of these people are paying out of their pockets for this. I don't know if that factors into it, but, as
the patient advocates, they really want to know if something is inferior
because this is coming right out of their pockets if not their hearts.
So
I would err on the side of caution before new drugs were introduced that this
noninferiority has been established.
DR.
EMERSON: I think one of the things you
will have is we are mostly, right now, talking--or at least I am talking
about--maybe I should have clarified this--but I am talking about the phase III
studies, the very confirmatory studies.
We have got, presumably, some phase II studies that are based on some of
these surrogate endpoints to argue we have good reason to be going forward with
this. And that is what you go forward
with the patients.
Again,
it is the clinicians who are involved with that, them knowing what sort of
enrollment they can get with the patient, what seems fair for the patient, in
their best judgment, and then IRBs and DSMBs take on a role there, as well.
DR.
GIUDICE: That brings us right into the
sixth question about single versus multiple treatment cycles. Any comments on that?
DR.
KEEFE: I'd like to pick up where I left
off in my talk. I proposed that we
consider the advantages of a crossover design.
I know there are a lot problems with that but it seems everyone agrees
there are enormous patient-specific factors at play here. So, while there is clearly a problem and you
have got a lot of people dropping out because they only got through the first
treatment, especially if you have proper controls in terms of two different
treatments being done, a crossover design would begin to touch on some of the
enormous variability from patient to patient.
What do you think, Scott?
DR.
EMERSON: That was an interesting
proposal, as I talked earlier. I hadn't
thought of that issue beforehand, of doing the crossover study, because I guess
I had been thinking far more of some of the other issues. The biggest problem I would see with that is
that patients dropping off the study not because they had pregnancy--that, we
could handle--but more just the idea that we would have one period of treatment
for them and not--but I guess I tend to think that we would gain more power
from actually taking multiple treatment cycles on the same arm or, certainly,
from my endpoint of interest which would be more time until we had a pregnancy
and taking advantage of--again, some of these treatments that are going to be
coming up will be trying to take advantage of cryopreservation, and what will
define your cycle, only one fresh cycle or the idea that you might have four cycles from a
cryopreservation.
DR.
GIUDICE: Dr. Hager, you had a comment?
DR.
HAGER: Merely, I was just going to say
it would seem to me that, if we do multiple trials, you would need to quantify
or in some way stratify for fresh cycle versus frozen cycle.
DR.
GIUDICE: Yes. Dr. Crockett?
DR.
CROCKETT: The other thing I like about
the multiple cycles is, in the single-cycle studies, I think there is more of a
temptation to blast the patient with as much as you can to get the highest
pregnancy rate. I worry about safety in
those patients. I think, if you allow
for a multiple-cycle trial, you can be more judicious about your treatment
options and maybe even start lower with your gonadotropins and not put the
patient at as much risk in an effort to have a higher success rate in your
study.
DR.
GIUDICE: We are talking, and I will
address this to Dr. Emerson--we are talking here for the phase III, so your
dose-finding studies would have been done before then, I assume. Yes?
DR.
EMERSON: But I think there are many
times that we, as a regimen, were testing the idea of the whole regimen. So it is not--I mean, there are a lot of
other ancillary things that are not related to the dose of this drug but the idea
of what other ancillary treatments they might be doing or there are a number of
implantations that they might do at a particular time.
Again,
if it is blinded, it is post-randomization, that is okay. If it is caused by the therapy, we would be
doing that. So it is sort of a level of
if you were using--I am imagining that if fresh were as good as cryo and that
you were more worried about multiple fetal gestations, that it might be
reasonable to start out with two and see if that worked and then, the very next
time, do more. And your facilitating
that if you allow the multiple cycle whereas you aren't allowing it if you do
the single cycle.
DR.
GIUDICE: Dr. Macones, Dr. Layman?
DR.
MACONES: I would just echo that. I think that, in my mind, in this case, I
think we really want to try to test what people do in practice. Not being an infertility doc, but, as I see
it, if you have a first cycle that fails, you go on to a second cycle. So to just limit it to a first cycle, to me,
makes no clinical sense at all.
DR.
GIUDICE: That will stir
controversy. Dr. Layman?
DR.
LAYMAN: I think, again, we have to get
back to the statisticians, then, because you are going to have cycle dependency
and that is going to have to be controlled for in the study, because if you
have one person who has had four cycles and one person who has had one, or
would it wash out in the randomization?
DR.
EMERSON: It washes out in the
randomization. Particularly, again, if
you are looking at an endpoint such as time to live birth, or time to
pregnancy, viable pregnancy or whatever, that is a concept. People who go through more cycles, well, that
is a deleterious effect, that they won't look as good as the arm in which it
worked the first time.
But,
working on the fourth cycle is better than never working at all and so it will
capture the endpoint you like.
DR.
GIUDICE: Dr. Toner and then Dr. Tulman.
DR.
TONER: My objection to the possibility
of multiple cycles is the lack of generalizability. At least if you are living in a nonmandated
state, as I am in, most patients get one try.
And that's it because they are paying their own way. To then come in with an offer of four
tries for free will induce different clinical
behavior on the part of clinicians. They
will maybe be more conservative. What
you learn that way won't reflect what actually happens.
So
I would be very afraid of opening up a different kind of a treatment strategy
than actually happens in practice.
DR.
GIUDICE: Dr. Tulman?
DR.
TULMAN: I just had two comments. One is, by having a crossover, would you, in
fact, entice more people to enroll because, on some of the cycles, they might
be getting what may or may not be perceived as the better treatment, although
it may not be the better treatment.
And
the other question I had to respond to Dr. Toner's last comment/ was that the
current practice of allowing one cycle may be based somewhat on the scientific
evidence, but if the scientific evidence changes, then that might also change
what is allowable for reimbursement.
DR.
TONER: I was only making the comment
that in Georgia--
DR.
TULMAN: Okay; maybe I misread you.
DR.
TONER: Most people can't afford a second
try. Even if it is to be encouraged on
the clinical grounds, they can't afford it.
So, to now offer it to a whole bunch of people who, in the real world,
would never have gotten past a first try, introduces a different kind of an
observed effect.
DR.
TULMAN: I guess I was just thinking
further in advance in that, if we became better at doing this, and the cost
were more allowable, and then the science would advance enough such that it
might be that one trial might not do it but two might be good. But if you have the evidence that two is
good, then that might eventually, somewhere down the road, become a more
reimbursable, or a covered, benefit.
DR.
GIUDICE: Dr. Crockett and then Dr. Rice,
Dr. Stanford and Dr. Lewis.
DR.
CROCKETT: I really get a little afraid
when we start talking about letting finances dictate how we are doing our
medical science. I understand completely
what you are saying about the practicality about funding for cycles. However, the fact that a patient can't afford
three cycles should not dictate how our physicians are treating those patients
for infertility.
For
instance, you know, our natural fecundability rate is about 20 percent. It takes most normal, healthy, fertile
couples at least three cycles to get pregnant, and that is normal and healthy
and okay. For us to be looking at a
medical technique that pushes that to 50 or 60 percent because that patient
can't afford to come back for those three tries, I don't really, from a
regulatory standpoint, want to encourage that type of behavior.
So
I would rather try to take that economic or that time pressure out of our
recommendations for that kind of trial.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: Dr. Emerson, what does it do for
the enrollment numbers if we use multiple treatment cycles and then you can
change the second cycle based on information that you gather from the first. If some of you all remember some of the
ovulation-induction trials with PCOS patients, if they didn't respond to a low
dose that first month, the second month, you could bump it up, or you could
bump it down, depending on what the trial was.
So
what does that do to your enrollment numbers?
DR.
EMERSON: Well, first, I should say that
those numbers that I gave you on sample size were based more on a binomial
proportion, just did they get pregnant or not, rather than what I would truly
advocate which is time to pregnancy, which would be a more powerful idea.
I
am not, therefore, as worried about the multiple--the nongeneralizability
because that will fall right out from the analysis. You will see that the time to pregnancy was
this many episodes and you would be able to judge that. If one arm had a higher overall rate over a
six-month period but the other arm had a higher rate at the first cycle--these
are crossing survival curves and you can use statistics that will identify that
if you want.
But
whatever it is, that will come out. So
this idea of, then, your question of saying, now this idea that we might tailor
treatment, that we would end up testing a treatment that allowed some
tailoring. Of course, we do this all the
time in diabetes. We don't prescribe a
single dose of insulin. We give a
constantly modifying dose.
So
it is possible to test such things if that is the strategy that you wanted to
test and as long as it was blinded, it wouldn't hurt anything, that we would be
doing the same modifications on both arms.
So
it is this idea of using these multiple times, we will be increasing our event
rate, particularly if we can switch into something that is measuring the time
as well as the probability of it occurring, we will be getting more useful
information.
DR.
GIUDICE: Dr. Stanford.
DR.
STANFORD: I just want to comment first
that the single versus multiple cycle advantages and disadvantages, again,
depends on your endpoints, not only your endpoints but your adverse outcomes.
For
example, just an example, if you had two regimens and one got you pregnant
faster in the first cycle, but the other one got you the same pregnancy rates
or maybe a little more after three cycles but with a lower multiple-pregnancy
rate, I think that would be a very important thing to assess.
So
my argument would be towards the total overall pregnancy rate for a course of
treatment, whatever you determine that is, because then you can look at things
like what is your overall multiple-pregnancy rate and maybe ovarian
hyperstimulation, other things that really should be factored in.
DR.
GIUDICE: Thank you.
Dr.
Lewis? No. Okay.
DR.
KEEFE: I have a question.
DR.
GIUDICE: Dr. Keefe?
DR.
KEEFE: It seems to me that multiple
cycles would be most helpful if our endpoint that we were looking at was pregnancy
rate, but, we can all agree that that is an extremely expensive way to bring a
new drug to market. If we are going to
be using other markers, especially noninferiority, it seems like to be able to
fund three, four, five IVF cycles--because what is going to happen is a
significant proportion of your patients are not going to get pregnant in either
group, even after three and four cycles, particularly as you get into the
mid-30s.
So
if we are going to use that, that is ideal.
That is perfect. That is the gold
standard. But, to have that burden, to
put that burden, on a new drug entering, it is a little excessive, maybe.
DR.
GIUDICE: I think we will probably get
into that discussion when we get to No. 8.
Last comment on No. 6?
DR.
LAYMAN: I have one other quick
question. I mean, does it make a
difference when you are using multiple cycles?
I have always been taught, you know, the patient is the experimental
group if you are looking at the efficacy.
Are you saying multiple cycles is reasonable to look at the time to
event in addition to just efficacy? Is
that what I understand? Is that what you
are saying?
DR.
EMERSON: With the multiple cycles, we
would have several choices. One is you
could use the cycle as the denominator and just adjust for the fact that we
have dependent observations, that we have measured some people more than one
cycle and we would have to account for that in the variability.
You
might also have to decide how you want to weight the fecundity rate. When I have five observations on one person
and two observations on another, do I want to weight that 5 to 2 or do I want
to weight that, that is one person and here is another person, which is more
important.
But
what I am suggesting is the time, measuring the time until they have a live
birth, the fact that it is multiple cycles or not would be dealt with the exact
same way. It is No. 9, but on an
intent-to-treat analysis, the question is, once we have randomized you to this,
just what is the time until you have had the live birth.
For
some people, it is going to be at infinity.
It just never happens. But we
know how to analyze that data and we find that same event, and then there is
not this problem because that is the unit that we are interested in, the
patient.
DR.
LAYMAN: So you are saying the key is you
correct for the--which has been the problem of some studies in the past where
there are multiple cycles and there was no correction.
DR.
EMERSON: Yes; absolutely.
DR.
GIUDICE: Let's take Questions 7 and 8 together because they both have to
with powering of the studies. We have
been requested to discuss advantages and disadvantages of powering studies to
detect a difference in live-birth rate or on ongoing pregnancy rate.
Dr.
Emerson, do you want to make a comment here?
DR.
EMERSON: I am not sure that the cost of
this--of the numbers that I have been bandying about are any greater than there
are in a lot of other diseases. So I
think the importance of answering the question that is the clinical outcome is
not subservient to trying to choose a surrogate outcome that is not answering
the question.
In
no clinical trials are we just looking for a pharmacological effect of the
drug. There are plenty of examples in
the history of clinical trials where the putative mechanism of the drug, the
drug did it. The antiarrhythmia trials;
we could give people drugs and decrease their arrhythmias. Unfortunately, we also killed them.
The
point was to find--we are trying to treat a disease here. The disease is infertility. We aren't trying to just see how many eggs we
can have from a particular ovulation.
The people who are wanting this treatment goes there. With an infinite amount of money, I would
love to study every single step in the whole mechanism that might lead from one
particular treatment to a good clinical outcome.
But
no one is going to pay for it. Once they
find out that it is a good clinical outcome, they are going to say, yeah, maybe
you know the mechanism, maybe you don't.
But I have got the outcome that I want.
So we are at this stage now where there is plenty of reason to suspect
that every treatment that we give may not have the same surrogate value, that
we might be intervening on the whole endocrine pathway differently with one
treatment than another, so the idea, here, is that if we stimulate ovulation or
the additional ova that we are stimulating equally as fertile as those that we
would get if we weren't stimulating as many.
We don't know those answers, so it is the pregnancy rate that will answer
it and, going in this sense, since you have the active comparator, that, by all
appearances, works fairly well, it is not really that big of a burden to be
able to demonstrate that you are not doing harm on the important clinical
outcome.
DR.
GIUDICE: I think you have just opened
Pandora's box. Dr. Lipshultz and then
Dr. Rice and Dr. Stanford.
DR.
LAYMAN: I'm sorry, but I have a question
on just what you said. So what you are
saying, then, is the only endpoint you think is significant is the pregnancy.
DR.
EMERSON: No. I think the primary endpoint of these
trials--for instance, I can imagine a scenario in which a new treatment is not
as efficacious as another active treatment but has other advantages. For instance, there may be situations that I
could imagine if you showed me one treatment that had a higher rate of
pregnancy in the first cycle, and another treatment that had still an overall
cumulative effect that was about the same, but in the first cycle, it wasn't, I
can imagine many scenarios in which I would accept that.
What
I was, instead, talking about was the primary endpoint and ensuring that we do
not have a treatment that is not efficacious against placebo. I mean, we are trying to estimate that in a
noninferiority situation with an active comparator. The idea that we would not power a study so
that you could even be sure that it was not doing as well as a placebo, I find
not in good science at this point.
You
would like to make certain that, as we are going forward and might approve a
therapy, that we would be certain that it is working better than placebo. We won't be certain that it is working better
than the active comparator, necessarily.
But then we have other secondary endpoints that I would certainly look
at. It is just the guarantee that we
aren't doing worse than doing nothing.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I guess my question is more so to
the FDA. How do you maintain the
equality if you have previously approved products based on one outcome and now,
if this committee were to make a recommendation to say now we want to use a
different endpoint. Someone new comes to
the market, how do you maintain that level of equality?
DR.
SHAMES: Well, I think that we are here
because we think, in fact, in the past, we have not--let's say this. Sometimes science changes. Things change and we have to keep up with the
science and do what we can--do the best for the public in terms of having the
science that we work with mimic the science in the community.
It
is not unusual for things to change and we are accused of being unfair. But this is not at all the only circumstance
where that happens. This happens in
other areas. Sometimes, we find safety
issues that we didn't know about two or three years ago and we compel companies
to do certain studies that we didn't compel other companies to do. We just find that we have to do that. We need to do the best we can at the moment
based on the science, even though that is perhaps not what we did a number of
years ago.
DR.
RICE: I think that, looking at
gonadotropins--I think you do reach a point with a certain class of products
that what comes onto the market, there is a level of equality in effectiveness
of an endpoint that you used to use but now the science has shown us that there
are more variables that go into that ultimate outcome.
I
brought this up to hope that it was based on all of the science that is coming
out even though our science in understanding ovarian reserve, et cetera, is
still growing, but that the science perhaps does dictate that we look at
different endpoints.
DR.
SHAMES: Absolutely, it should.
DR.
GIUDICE: I would like to ask the
committee for some input in terms of what other primary outcomes--does
everybody agree, now, that the primary outcome for, for instance, gonadotropin
therapy should be pregnancy? We have
heard from Dr. Emerson and I think this is where--and I think Dr. Lipshultz's
question addressed this. Dr. Stanford?
DR.
STANFORD: I would just like to
clarify. Are you talking about, Dr.
Emerson, chemical pregnancy, clinical pregnancy, or live birth?
DR.
EMERSON: Well, I guess my top choice
would be live birth. While I liked the
suggestion earlier that it should really be live healthy birth, I think that
there is trouble with healthy birth. So
my first choice would be live birth and, if you have to take me to lesser
things, it will be going backwards from live birth.
DR.
STANFORD: I would agree with that.
DR.
GIUDICE: Dr. Keefe?
DR.
KEEFE: If you looked at Dr. Toner's
graph at the relationship between miscarriage and take-home baby, it seems to
sort of parallel. So I think it is a
crude but good indicator of what is going to happen. You could imagine a number of interventions
that might selectively perturb the development of the embryo after that, but I
think, in general, on balance, it is probably the best sort of practical
measure we have short of live birth. This
would be clinical pregnancy or with a heartbeat.
DR.
GIUDICE: Dr. Toner and then Dr.
Lipshultz, and I saw another hand down here.
Dr. Hager.
DR.
TONER: I would still vote for some
measure of follicular response, the primary pharmacologic action of the drug in
question. I think, if we choose
pregnancy, as I said this morning, if a drug these days proved more potent in
egg production, it would be invisible to the fresh pregnancy rate. So an
apparent benefit is completely invisible.
Now,
sure; it could go the other way. But we
clinicians are actually in the business of trying to get pregnancies and not
trying to get eggs despite what I might say otherwise and it wouldn't be too
long before an inferior product with respect to the ultimate endpoint would
come to light and change practice.
Already,
all the studies that have focused on egg-production capacity have disclosed
pregnancy rates. So it is not like the
data would be unavailable if we stuck with the same endpoint as has been used
heretofore.
DR.
GIUDICE: Dr. Lipshultz?
DR.
LIPSHULTZ: It's really not a question
for you because, I mean, I am coming from a specialty where we don't have such
a long delay in waiting for an outcome.
But if you are a company developing a drug and your outcome is nine
months after you start giving the medicine in question, the drug in question,
let alone the start-up time and getting your patients enrolled, what are you
looking at, realistically, until you get something--data together that is going
to be significant enough to present and, in the meantime, science is changing
and you are taking three years to do a study, with the numbers you talked
about.
I
mean, if you just use live birth as an endpoint, I am questioning just how long
such a study would have to take.
DR.
EMERSON: In a time-to-event analysis,
you actually measure the amount of data you get by the number of events. So the question is how long do you have to go
until you have so many events, and you power it according to that. Of course, cancer in clinical trials
routinely takes years and years and years.
So this isn't anything that is out of the ordinary in the experience of
clinical research.
DR.
KEEFE: Can I respond to that one?
DR.
GIUDICE: Yes; Dr. Keefe?
DR.
KEEFE: There is a real practical issue
as well. People disappear. They got their babies; like, sayonara, they
are out of there. I mean, the person who
is treating for infertility is not the one who is going to deliver the
baby. So it is really hard just to find
these people. They move. They go to different places. They deliver at another hospital. So you can't get the data, even in a really
carefully controlled study.
One
other point, though, about using the egg number or follicle number, there are
precedents in which you get more eggs but there is a worse outcome. Klaus Dietrich, for example, just looking at
a subset, those with lower response, has shown that the flare, the
old-fashioned flare, actually gives you more eggs. It gives you higher estradiol response, but a
lower pregnancy rate than some of the other methods.
So
it is a little tricky just to look at egg and follicle number. So I would say clinical pregnancy is kind of
a middle ground.
DR.
GIUDICE: Dr. Hager?
DR.
HAGER: I understand the pharmaceutical
perspective, the research perspective, of power and design in trying to get as
many positives, if you will, regarding follicular development, regarding
oocytes. At the same time, my patient
population, they are not interested in a chemical pregnancy test. Their perspective is that they want to get
pregnant.
At
the same time, given my understanding that if we have a gestational sac with
fetal heart motion, there is a 95 percent chance of carrying that
pregnancy. Then, I think that gives that
patient the same odds as a patient who conceives outside of an
assisted-reproductive-technology situation.
So
my perspective is that my endpoint would be fetal heart motion. I realize that we would all like to have a
live baby but I don't think that is the endpoint that I would like to see with
these medications. I would like to take
it to fetal heart motion.
DR.
GIUDICE: Dr. Layman and then Dr.
Brzyski.
DR.
LAYMAN: I think, to me, it is different
depending upon the implication. Like,
for ovulation induction, for Class 1 patients versus Class 2 versus using for
ART, for ART, it seems more clear to me that it should clearly be
pregnancy. But, at the opposite extreme,
I think Class 1, I think it is not practical to use pregnancy as the
endpoint. You will never get enough
patients to do it.
So
I think you have to sort of bear in mind how common it is. I think Class 2 is a tougher one. It is sort of in between and I don't view all
three of those the same.
DR.
GIUDICE: Dr. Brzyski.
DR.
BRZYSKI: I think I brought this up
earlier but especially in the PCO population, there is a real problem with
miscarriage rate and also in infertile populations, not only in advanced but
just the infertile puts you at increased risk of miscarriage even after the
documentation of cardiac motion on ultrasound.
So
I think you do lose something, and you can imagine an intervention that--I
mean, there is some scientific evidence now for an off-label use of a
ovulation-induction medicine that is used to induce ovulation in PCOS
patients. One of the attractions to that
is, because of the lower miscarriage rate in PCOS patients. So that becomes an important endpoint that
you might lose if you focus on cardiac motion or positive pregnancy test.
DR.
GIUDICE: That does bring us into
Question 8, but I think Dr. Rice had a comment.
DR.
RICE: I was just going to say, I agree
with Dr. Layman. I think it really does
depend on the type of patient you are looking at. If I have an anovulatory patient, then I may
have a trial that really just looks at getting that patient to ovulate as the
endpoint. In that patient population,
that would be adequate because of what the patient came to the table with.
But
when you are looking at ART patients, I think that it should be fetal-cardiac
activity on a ultrasound because, again, as Dr. Hager was saying, there is 95
percent chance of success once you have that.
I
also would say to Dr. Keefe, I can bet you, and I don't think I am wrong about
this, that most of the pharmaceutical companies know whether or not those women
that had a positive pregnancy test delivered that baby. They track that information. I would be surprised that they didn't track
some of that information.
The
FDA sort of alluded to it earlier, that they know they report some of that
information. At least, there is some
information regarding it; is that correct?
So I would be surprised that they don't know some of the outcomes of
that data. So I think that data is
obtainable.
DR.
GIUDICE: That I think we can get to in
Question 13. Let's move on. With regard to the pregnancy or the outcome,
we have already discussed, not really follicular development rate but follicle
development. As you can see from
Question 8, the issue is, if you can't power to demonstrate differences in live
birth, or ongoing pregnancy rate, then discuss the clinical relevance of these
surrogate markers. Dr. Crockett?
DR.
CROCKETT: I just have a question
concerning our discussion of these endpoints.
In my mind, it seems like it would be easier to separate out what we
look at as endpoints for efficacy versus endpoints that I would consider for
safety considerations.
For
instance, for efficacy of an ovulation drug, I think follicular development is
an acceptable endpoint. But I might want
to know more about that drug such as does it cause teratogenesis of some kind. I am not aware of that being a problem with
any of our current medications, but it is conceivable that, in the future,
there could be drugs that do that.
So
it would probably be helpful for us, from a safety standpoint, to follow out
those patients to a pregnancy or even beyond pregnancy endpoint since we know
that genetic factors can carry even beyond birth. So I just wanted to raise that question.
DR.
GIUDICE: Thank you. Other comments? Going through the list here, I think we have
heard, with anovulatory patients, that follicular development--we haven't really
defined follicular development, whether we mean follicles of a given size or
estradiols over a given level or endometrium over a given thickness. Would someone like to make some comments
about that? Or should we include those
as possibilities for recommendations as we advise the FDA? Okay.
DR.
KEEFE: In each of these, it seems that,
as you push back further, it makes it easier to do and you need less power, but
it always raises the question of is there a downside to the treatment later in
development.
So,
just to balance these--some, for example, have argued that for ovulation
induction, all we need to do is show that they have ovulated. But there are many ways to make people
ovulate that almost guarantee there would be a miscarriage. You could drive the LH level so high that
they may ovulate but it is not going to develop.
So
I would say that, in general, for most of these things, to try to paint with
broad strokes, would be that these are useful indicators of efficacy unless
there is some scientific evidence to suggest a detrimental impact at later
stages of development. So that would
open the door to concerns of--for example, we had an intervention that drove up
LH levels too high--that maybe, in that, there might be a little bit more
concern about showing more than just ovulation, ovulation with development of
fetal heart, and then, if there is some evidence of a treatment causing higher
rates of miscarriage after fetal heart, that efficacy should be determined at a
later stage of development.
DR.
GIUDICE: Okay. Yes; Dr. Emmi?
DR.
EMMI: I remember reading a study a
couple of years ago that showed that it wasn't just fetal heart. It was when, in the first trimester, fetal
heart was obtained, whether the pregnancy would continue to go on. And that was based on age. The older patients, if they didn't have the
fetal heart at about eight to ten weeks, had more chance of a miscarriage.
So
I don't think that you can just go clinical pregnancy. I think you have to pick a parameter. If you are going to pick clinical pregnancy,
you have to pick a time in the first trimester for that ultrasound to be
performed to establish it.
DR.
GIUDICE: Dr. Emerson?
DR.
EMERSON: I have already stated that I
sort of wouldn't go beyond the presence of the gestational sac, personally, and
I would prefer not stopping before fetal heartbeat. I do want to point out that if your whole
goal is that you think that they can't get a sample size large enough to detect
this, you are also guaranteeing absolutely that you won't have a large enough
sample size to be able to detect a meaningful rate of fetal abnormality or
miscarriage because if you don't even have a large enough sample size to
observe that you have got a difference in pregnancies, by the time you have reduced
that sample size, you have got a very small sample size of pregnancies to work
for.
Seeing
zero events, zero events, your confidence bound on a bad event rate is roughly
3 over n. The space shuttle went off 24
times without a catastrophe and the next one blew up and we now know that that
rate is actually far higher than you might have thought with just 24 no
failures.
So
we are making a decision truly as you want to power this down for the clinical
endpoints of interest is also we won't be able to detect meaningful
adverse-event rates.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I can't see why we would think we
would not be able to enroll enough patients in, say, a trial because if you
look at, just from the Follistim data she showed, what was it, under a thousand
patients in those two arm, to detect a difference. We had approximately 160,000 people maybe
last year who used--maybe 100,000 who used gonadotropins, 40 percent of that
for IVF, the other percent just with ovulation induction.
So
you are talking about 100,000 people in a given year and we can't come up with
2,000 to detect a difference in a product?
That would seem unreasonable. I
can't imagine that.
DR.
GIUDICE: That may be true for pregnancy,
for infertility, but if you get the Kallmann's patient, for instance, there you
probably will not--I think what Dr. Layman was referring to was the WHO Type 1
and even subsets within that where getting enough patients for power is nearly
impossible with a few thousand worldwide.
DR.
RICE: Clearly, there are going to be
some limitations when we get to specific disorders like that. And we have all seen, in some of those
studies, you change your endpoint because you recognize that the disease is so
rare that you could not potentially use pregnancy as the outcome.
But
if we were looking at infertility, and I would even venture to say we were just
looking at "anovulation," the anovulatory patient, that there may
potentially still be the opportunity with the incidence we see the disease
process in to enroll enough patients.
DR.
GIUDICE: I would like to ask the
committee, in terms of pregnancy rate for the list here, what the consensus is
in terms of recommendation to the FDA, if pregnancy is going to be an outcome. Is it positive beta-hCG? Is it a sac on ultrasound? Is it a sac with a heartbeat? Is it a sac with a heartbeat at six weeks or
eight weeks?
Are
we going to give a definitive recommendation or leave the list and have that
open for interpretation and discussion at the FDA by the FDA? Dr. Keefe?
DR.
KEEFE: I would advocate, as was argued
very persuasively, that a fetal heart is a big quantum leap, once you have the
fetal heart detectable conventionally around six weeks. So I would vote for the fetal heart. You know, on balance, it is practical,
doable, and it is a big hurdle that the embryo has overcome.
DR.
GIUDICE: Dr. Hager?
DR.
HAGER: I think the other advantage is
that it is a reproducible event to measure.
DR.
KEEFE: It is under the control of the
clinic that is doing the study.
DR.
GIUDICE: Can we take a vote on this
one? Okay. Who is in favor in the definition of
pregnancy as the outcome for sac and fetus with a heartbeat. Anyone opposed? Dr. Stanford.
DR.
STANFORD: I would think that you could
set it as a minimum standard. That is
what I would be comfortable with. I
think, in some cases, where there may be safety concerns that go beyond that,
you would want to allow for having a higher standard in some cases where there
is a reason to do so.
But,
if you state it as a minimum standard, I think I would be happy with that.
DR.
GIUDICE: Okay. Yes; Dr. Hager?
DR.
HAGER: Just a comment. I would think that there would be a strong
emphasis for follow up and tracking, et cetera.
I think we have already conveyed that.
So this would be a part of that is what is the ultimate outcome and,
also, I would hope that we would encourage follow up regarding anomalies and
aneuploidy, et cetera.
DR.
GIUDICE: Thank you. Let's move on to Questions 9 and 10 regarding
intention to treat. So the first one; is
an intent-to-treat analysis appropriate for ovulation induction and, if not,
should cycles be analyzed per patient given hCG? Any comments on that?
We
have heard Dr. Emerson. Perhaps he would
like to restate his statement.
DR.
EMERSON: You know, randomization--you
are only protected by randomization if you do intent-to-treat. Otherwise, you are not.
DR.
GIUDICE: Yes. Dr. Lewis?
DR.
LEWIS: I think you have to use
intent-to-treat for both ovulation induction and ART because also cancellation
rates are very important and, if a given drug is associated with a higher
cancellation rate for whatever reason, you want to know about it. So I think the other endpoints are really not
so meaningful, or the other denominators are not so meaningful, I should say.
DR.
GIUDICE: Yes; Dr. Toner?
DR.
TONER: I would concur. I would just argue, hopefully, for
flexibility in the stimulation arm because, if you constrain every patient to
get the same dose, and you are under on some and over on some, you are going to
get hardly any to the finish line. And
you will look like you didn't do well, but it is because you had your hands
tied behind your back.
So
I think that was the problem with some protocols that have been done to date
and would need to be changed.
DR.
GIUDICE: There seems to be pretty good
consensus among the group about intent-to-treat. Going on to No. 11, to discuss safety
endpoints that should be evaluated. Dr.
Stanford?
DR.
STANFORD: I will just say, again, I
think multiple gestation definitely ought to be on the list. Certainly, there are others that we have
talked about, ovarian-hyperstimulation syndrome, obviously ought to be on the
list.
DR.
GIUDICE: Others? Yes; Dr. Crockett?
DR.
CROCKETT: I have a lot of concern about
this. I, in particular, am concerned
about the risk to the mother being given these drugs or hyperstimulation, not
just the immediate effects of the ovarian-hyperstimulation syndrome but are
there oncogenic effects further down her lifetime. So, while it may not be a factor that we need
in order to make a decision about certifying a drug for use, it may be
important to us, as an agency, to know how those patients, both the maternal
side and the fetal side, progress 20, 30, 40, 50 years out.
And
we ought to consider having a registry of adverse events just like we do for
many other drugs, far out.
DR.
GIUDICE: Thank you. Any other comments? Dr. Hager.
DR.
HAGER: Bringing up the clomiphene
situation long-term, I think, as Dr. Crockett has said, there needs to be a
definite registry not only for immediate disease but also the long-term
oncologic effects. I would hope that
would be designed into all of these trials so that we not only follow the
infants but we also follow the moms.
DR.
GIUDICE: I think you both make very
important points and I think one of the major questions is--actually, there
were several questions--who would run and have control over a central registry. Would it be one individual pharmaceutical
company? Would it be the FDA? Would it be the CDC? Would it be SART? Would it be ASRM?
Complementary
to that is the whole issue of cost, who would fund the registry. These are issues that I don't know that our
committee can solve, but I think, and this certainly bears very much on
Question No. 13--but this is something that I think we need to at least discuss
in a little bit more detail because I think we are all aware of these issues
but, perhaps, we can be of some help to the FDA in making some recommendations.
Dr.
Lipshultz?
DR.
LIPSHULTZ: Just a comment because I
randomized up against this recently.
Apparently, as physicians, we all have the duty to report to the
pharmaceutical company any adverse event we find in a patient, no matter what
they are taking, related to that drug. I
just don't think we, as physicians, do that.
We
find things. We have patients who
develop malignancies and we think it might be related to something, and we
never let the company know because we are not part of a study. I mean, these people, after they go through
IVF are no longer going to be part of a study, or part of a group. They are going to move on with their lives
but they will all have doctors.
So
I don't know whether it is anybody's, any agency's or any subgroup's
responsibility, as it is the medical community's responsibility to make sure
that all adverse events are reported to the pharmaceutical companies if you
think there is a connection.
DR.
GIUDICE: Dr. Crockett and then Dr.
Keefe.
DR.
CROCKETT: I think this is a
public-health problem. I don't think
this is a pharmaceutical-industry thing.
Frankly, no disrespect to our pharmaceutical people that are in the
audience, but I don't trust the drug companies to take the whole public
interest to heart. I think that is why
we have agencies like the CDC that track other public-disease problems.
I
would suggest that should become part of our responsibility in that regard.
DR.
GIUDICE: Okay.
DR.
KEEFE: I agree. If you really want it to work, you don't go
to the pharmaceutical companies. You
don't depend on doctors. You put it out
there, maybe foundations, CDC, a number of sort of public-interest groups, and
the patients will help us because they will start calling, they will start
reporting. They will say they have a
friend who had this or that, and all the chat rooms. That is how to make it work. Then you really have data.
There
are registries available. The
Australians have a registry. They have
published extensively on long-term outcomes and they are not finding a lot. But they are looking more at cancer, I think
the developmental anomalies, aneuploidies, other issues regarding the offspring
and potentially other issues regarding the patients.
But
I think it has to be outside everyone and of its own domain funded externally. Then it will work.
DR.
GIUDICE: Dr. Dickey, you had a
comment? And then Dr. Hager?
DR.
DICKEY: Judging from some of the other
things that we fund externally to keep registries, that doesn't work so well
either. They are dependent on state
funding which comes and goes. But I do
think the whole conflict of interest thing that we are so attuned to here
suggests, in fact, that it would probably be better if it came from some
centralized entity as opposed to expecting the pharmaceutical industry to track
that.
I
don't have a great deal of faith that either doctors or patients, in fact, do a
very good job long after the fact of trying to correlate back what
happened. So I think you have to have a
little more specific guidance out there of who you need to report to you and
what kinds of things you want reported and, perhaps, then chat rooms and things
can do it.
But
very few of us, in fact, correlate something back to something that happened
twenty years ago or thirty years ago.
And I am not sure how you get somebody to fund it.
DR.
GIUDICE: Dr. Hager?
DR.
HAGER: There is precedent. When metronidazole was approved by the FDA as
an antianaerobic agent, there was some rodent data at the time that indicated
the potential for some problems. I was
at the CDC. We began a registry at that
time looking at deleterious effects in newborn infants.
As
you know, we have discontinued that registry because there are none. But, there is precedent for cooperation
between the two agencies to develop a registry and to follow that, and it is a
public-health measure.
DR.
GIUDICE: Dr. Macones, Dr. Lewis and Dr.
Brzyski.
DR.
MACONES: I agree that I really see this
as a domain of the pharmaceutical company to put together a registry for
this. I think I could see this
discussion happening with the NIH coming up with, developing a long-term follow
up for a cohort of people who were exposed to ART drugs. I think there is some precedent for a very
successful long-term follow-up physicians health study, nurses health study,
that have been remarkable.
I
just can't see how a 40-year follow-up study is going to be the responsibility
of a pharmaceutical company. I think
this needs to be independently funded and I think the NIH would be very
receptive to something like this.
DR.
GIUDICE: Dr. Lewis?
DR.
LEWIS: A registry could provide
enormously helpful information. I think
you have to be very careful about privacy concerns of patients, particularly in
this day and age with HIPAA regulations.
So it would have to be, obviously, voluntary. I don't think it is realistic to think the
pharmaceutical industry is going to pay for it.
One
thing about patients recollections, it has been shown quite clearly that if a
patient develops a disease, they recall very clearly every single thing they
ever took. So recall bias could be quite
a problem so you really do have to think about doing it prospectively. But it is very expensive and there are a lot
of obstacles in the way.
DR.
GIUDICE: Dr. Brzyski?
DR.
BRZYSKI: One point I would like to raise
is the issue that we really don't have good information about complications,
first of all, even in the general population.
There is a quote--I tried to track down a reference for the commonly
cited rate of 2 to 4 percent for severe birth defects. I can't find it. It is on the CDC website, but there is no
citation for, like, where that rate comes from.
If
you look--well, anyway. And then if you
look at infertile individuals who may have other predispositions, genetically
or epigenetically, to have complications or problems down the line, really, we
have no information on that population compared to, say, the ART population
where there is concern about, for instance, birth defects in the children.
So
when we look at a registry, if all we have is a registry of people exposed to
fertility medications, I am not sure how to put that in perspective in terms of
the general population or in terms of infertile individuals who were not
exposed to fertility medications. So now
you are doubling or tripling your effort to collect the data on those other
populations so you can make some comparison about, well, is the rate of 2 per
10,000, is that bad or good compared to other individuals.
DR.
GIUDICE: Thank you. Another question also is what type of
information would be collected for this type of registry. I think, certainly, now that there are
potentially three populations to collect information on. This does bring up even yet again a larger
database but I would like to hear--perhaps we can discuss, as a group, some
potential entries into this hypothetical database. Dr. Crockett?
DR.
CROCKETT: Well, let's start at the
lowest end which would be adverse events during the pregnancy that you wouldn't
have otherwise expected. So I would want
to know fetal anomalies identified by ultrasound and a fetal-loss rate beyond
the first trimester, perhaps.
Beyond
that, after birth, then tracking out the infant or the baby, I would want to
know about specific diseases, particularly oncogenesis, learning disability,
diseases which we are concerned about now with other drugs that we are
introducing into our pregnancy women.
From the maternal side, I have already mentioned, oncogenesis, also.
DR.
GIUDICE: Thank you. Dr. Toner?
DR.
TONER: I was just going to mention, kind
of following up with what Bob had said, that every state in the country has its
own rules about how to do birth-defect reporting. There is no consensus about what is in the
list, what is off the list, who collects it, when it is observed. So that is partly why Dr. Brzyski can't find
a reference, because it is done a hundred different ways.
Probably
the most simple thing to do would be to go into a state that already does it
across the board and then parse them up by, are these IVF babies or are these
not so you don't focus undue scrutiny on the IVFs and don't apply that same
scrutiny to everybody else.
As
I understood the CDC, they were trying to get such a thing to happen in
Massachusetts where there is potential for linkage. But in most states, because of privacy
concerns, you can't know who the baby is, who the mom was and who got
treated. So it is going to be very
tough, I think, except in a state potentially like Massachusetts.
DR.
GIUDICE: Dr. Keefe?
DR.
KEEFE: The Dutch have done that, of
course, published. They looked at one
particular outcome which is adverse neurological sequelae and found huge
increases. Those were in group homes
where the most severely impaired live.
And so there is much less detection bias.
It
is true there are problems, but there is such precedence for it being such a
large impact and the vast majority of the abnormalities, by the way, were
linked to multiple births and prematurity, as you would expect.
So
now it looks like I think 2 percent of all births in Sweden come from IVF
babies. It is going to grow in the
United States. I think we should start
planning now. I think it has got to be
done. I mean, look at DES,
diethylstilbesterol. This was the
previous generation's new technology. It
was some well-meaning, brilliant Harvard professors of biochemistry and GYN who
had this tremendous theory of the value of estrogen in early pregnancy which
made a lot of sense then but, in retrospect, is laughable, how naive it was and
led to some really adverse outcomes.
So
I think it is way too big and way too important to say it can't be done. It is just a question of how, really.
DR.
GIUDICE: But the specific question from
the FDA was whether the pharmaceutical companies would need to be responsible
for these registries. What I think I
have heard from the group is that this is way bigger than any one
pharmaceutical company. Dr. Rice and
then Dr. Stanford.
DR.
RICE: I agree with Dr. Keefe. I think just because it is hard doesn't mean
that we shouldn't do it. I think we need
to do it. I think it is going to be
valuable information that is going to find invaluable as we look at long-term
outcomes. And I do think it is bigger
than the pharmaceutical companies. So I
don't know if I would put, per se, the burden on them to do it.
I
don't know where the burden, per se, falls but I think it definitely needs to
be done because we are treating too many women at this--we are treating so many
women at this point that, at some point, we are going to get to a point where
we can actually detect some differences, and those differences may be very
significant in looking at not only fetal outcomes but maternal outcomes, also.
DR.
GIUDICE: Dr. Stanford?
DR.
STANFORD: Just a comment. It is probably stating the obvious but maybe
just a comment that the FDA would welcome the assistance or cooperation of the
drug companies in these efforts as opposed to you should do this, or this has
to be done somehow, and stating that that is a
desirably--obviously, that doesn't have any teeth, regulatory teeth, but
just as a statement of policy that they would appreciate cooperation or
assistance in terms of tracking people from trials or whatever that may come
up.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: And we are talking about a
registry for ovulation-induction patients and ART patients because we get
caught up in the ART part of it but the ovulation induction is mostly what we
see. Our gonadotropins are usually
patients who use insemination or time to intercourse, et cetera, and that. So we want to make sure that we are talking
about areas.
DR.
GIUDICE: Yes; I am glad you clarified
that. Thank you. Dr. Brzyski?
DR.
BRZYSKI: One comment, one
recommendation, I would have is I hear from my colleagues that there is concern,
and we have talked about it here, concern about privacy. I mentioned, myself, the stigmatization of
offspring. There are, perhaps,
educational efforts that need to be made in the patient populations and that
would be the efforts that professional societies could make, patient-advocacy
organizations could make. Even the FDA
might be able to inform the public regarding the relevance of--you know, if a
registry is established, the importance of participating in that and educating
patients and families and physicians about the public-health impact of that
registry.
DR.
GIUDICE: Thank you. Yes; Dr. Crockett?
DR.
CROCKETT: I just wanted to add one more
thing to that. A registry is really
helpful but the other part of this is informing the patient about what
knowledge is available concerning the medications that they are taking and what
knowledge is not yet available.
For
instance, on the product labeling, there probably should be a statement that
makes the patient aware of the safety data and efficacy data that has been
looked at and the terms of those studies and the limits of those studies. If we had done that with hormone-replacement
therapy twenty years ago, then we may have had a little less trouble dealing
with the questions of that whole breast-cancer issue.
I
think people, when the FDA says something is approved, they have the assumption
that it is safe and it is efficacious for the nth degree. If we are establishing safety for a short
period of time that we are looking at, it needs to be made clear in the
literature to the patients.
DR.
GIUDICE: That is a very good point. Dr. Rice?
DR.
RICE: I think we ought to be very
careful about that because we can only use the information that we have
currently to make those limited statements on safety. So we don't want to be using level 2 or 3
evidence to say what safety is. So you
want to be using--you want to be very careful about that because, when you used
the hormone therapy as an example, based on when the information was presented
to the FDA, when they wrote those guidelines, that was the best information
they probably had then.
It
changes over time. So I think that is
the key thing. You ought to keep the
flexibility so that you can change it as more--as the best evidence becomes
available.
DR.
CROCKETT: So that again. That is exactly right.
DR.
RICE: I don't know how I said it.
DR.
CROCKETT: The patient needs to know
that, though.
DR.
RICE: Right. The patient clearly needs to know this.
DR.
CROCKETT: That this is based on our best
information right now and that it may change over time.
DR.
RICE: But I think there are
different--there is different quality of evidence. If that was the case, then, we could take
some studies now and put a potential oncogenic risk to taking infertility
drugs. But many of us would say that
that evidence is not based on anything prospective. And so you wouldn't want to put that on the
label to unduly scare the patient at this point.
DR.
CROCKETT: You misunderstood what I
said. Let me clarify.
DR.
RICE: Okay.
DR.
CROCKETT: I didn't want to say
specifically that there may be a risk of X, Y and Z that has not been
discovered yet. I mean merely that we
would tell the patient what has been discovered and what the time frame is of
that discovery and that there may be, in a general way--like you previously
stated, there may be risks in the future that are undisclosed at the time that
the drug was approved.
DR.
RICE: But then you have to ask the
question which risk. You know, that is
the thing, which risk. There are several
possible risks that could be there.
DR.
CROCKETT: There are a million possible
risks.
DR.
RICE: So your possible risks needs to be
based on some good evidence.
DR.
CROCKETT: No. There are a million possible risks that we
take with anything that we take into our bodies, but the patients, when they
see something from the FDA that says it is approved, the patient and the public
think that that means it is safe forever and ever. And we ought to be able to tell them, no, we
have looked at the safety and efficacy regarding these things in this short
period of time, and there may be things that we don't know about yet.
We
don't have to list what those things may be but we need to at least disclose
the limitations to what we know.
DR.
GIUDICE: I think it is an obligation of
clinicians who are prescribing medications to inform patients about risks and
benefits and also to give them the package insert so that they read all of the
information. But I think what you are
getting at is, in the package insert, some statement should be made, perhaps
more clearly, that there are limitations to the evidence.
DR.
CROCKETT: Yes. The whole reason I thought to bring this up
is because, if we are talking about a registry, it would be helpful for the
patient, when they get that medicine, to know that, if they have an adverse
effect that was not discovered at the time the drug was approved, that they
need to report it to somebody.
DR.
GIUDICE: Yes. Thank you.
We have one more question to do and that is No. 12. Oh; there was part of 13. At what point should a registry be
terminated. I think, perhaps, Dr. Hager
described quite well the CDC experience that if there is no difference, then
why continue to have a registry and spend the money, et cetera.
Unless others have additional comments
on that.
Okay. It states here that drug manufacturers
conducting studies for female infertility currently obtain the following
indications; induction of ovulation in pregnancy and multiple follicle development
in ART. Please comment on the
appropriateness of these indications given your discussions of endpoints and
analyses.
I
would like some clarification on exactly what the question is. Are you asking us to comment on other
potential studies or are these the only indications that should be sought?
DR.
SLAUGHTER: These are the current label
indications that are either induction of ovulation or induction of ovulation
and pregnancy or multiple follicular development and ART. Would you comment on whether or not you would
modify, given all the discussions that you have had on the endpoints, et
cetera.
DR.
GIUDICE: Dr. Emerson?
DR.
EMERSON: I'm in favor of an indication
that indicates it is pregnancy when that is the endpoint. So the only way that I could imagine that the
multiple follicular development and ART indication should go forward is at the
point that we did develop the technology for cryopreservation of oocytes. Well, then, that would become the endpoint in
itself. But I would imagine that should
happen when we also feel more comfortable that that is the ultimate goal.
So
I would want to add pregnancy on the follicular development and I would like to
make it that it is induction of ovulation and pregnancy not just induction of
ovulation.
DR.
GIUDICE: Dr. Stanford?
DR.
STANFORD: I would support that. It seems to me what we are basically saying
is that some drugs have been approved for ovulation induction and pregnancy
outside the IVF setting and then other drugs in the IVF setting have been
approved, or sometimes the same drugs, simply for follicular development.
It
seems like make it the same standard.
Make it pregnancy across the board is what we are saying, it seems to
me. Now, I would also say, though, that
if we talk about some potential exceptions to that, I am still--if there is
some kind of rare condition where there are not enough numbers to do that, I
think that may be another discussion.
But I think whenever you have got the potential--I agree that the basic
gold standard should be the same across the two types of therapy.
DR.
GIUDICE: Other discussion? There may be rare instances where individuals
may have ovulation induction and even oocytes retrieval but then elect not to
have embryos transferred for the purpose of establishing a pregnancy such as an
ongoing malignancy.
But,
again, these are very, very rare. So I
don't know how that would be handled. I
guess one can certain prescribe medications off-label or at least not for these
indications but the issue is really for the study. Yes; Dr. Emerson?
DR.
EMERSON: But in that instance, wouldn't
they be doing this in order to have a later pregnancy? The
indication why they were doing this for in the case of the cancer
therapy was to protect the idea that they might later want a pregnancy.
DR.
GIUDICE: Yes; but for a pharmaceutical
company, if the endpoint is pregnancy and your patient population is a cancer
population, that may be a very long time before you end up with an outcome.
DR.
EMERSON: So I guess I am saying that I
wouldn't imagine them running a clinical trial specific to cancer patients just
prior to chemotherapy. But, once you are
confronted with facing chemotherapy, it seems quite reasonable to pursue something
that would preserve your childbearing potential and, if there was a drug that
did that, we have got that indication.
DR.
GIUDICE: Other comments? Dr. Keefe?
DR.
KEEFE: If we added that to the
indication, doesn't that sort of lock in pregnancy as the only outcome that
would be permitted in terms of the acceptability of a new drug? It seems to me that we just had that
discussion earlier and there was a little bit of debate about that. So I am just a little bit concerned that that
goes into the indication.
We
have a chemotherapy drug and we are saying that life is the outcome. You might be able to cure a cancer, but these
are in 90-year-old patients. It seems
that multiple follicular--it is very clearly connected to the outcome. I am sort of voting for flexibility in that
and I am just afraid that we may lose flexibility if we put it into the
indication.
DR.
SHAMES: Some companies could elect to
have pregnancy the outcome and some people could elect to have follicular
development. I mean--
DR.
RICE: But if you were a company, which
one would you select?
DR.
SHAMES: Depending on how the trial is
run, you need to match the trial to the indication. To use your oncology analogy, we don't expect
everybody to get pregnant. It is a
proportion of people that get pregnant.
Generally, we try to match the indication to the clinical trial and what
is important. If pregnancy is important,
that would be the endpoint in a particular trial and that would be the
indication they got.
It
is possible, under certain circumstances, for some unusual circumstances, that
there would be others and that would be the indication that they would get.
DR.
GIUDICE: Dr. Toner and then Dr.
Slaughter.
DR.
SLAUGHTER: I guess the only comment I
would have is that, as we talked about, should the science advance to the point
that we have a surrogate that we really do think is a predictor. It is possible to modify the guidance
document at that time.
DR.
GIUDICE: Thank you. Dr. Toner, you had a comment?
DR.
TONER: I was wondering whether sort of a
hybrid indication such as follicle development for pregnancy might better
capture what the gonadotropin part of this process is about. And to say pregnancy would apply for any of
the components in the whole process that would pertain to the progesterone we
are using or the hCG we are using. Why
are we using it? For pregnancy. So maybe we want to be a little more specific
than pregnancy undefined.
DR.
GIUDICE: Dr. Rice?
DR.
RICE: I guess I am confused. Didn't we discuss this already? I mean, what did we vote on? I guess I am confused about why we are
backtracking here back down this because I thought that the whole--when
everybody was polled, we were saying fetal cardiac activity, et cetera.
DR.
KEEFE: Since I am the one who brought it
up, let me explain why.
DR.
RICE: Okay.
DR.
KEEFE: I think once you put it in--it is
a different level. It is a different
burden. It is one thing to recommend
that it be used as the outcome. It is
another to put it as an indication. To
me, it is another level of--another burden that you are incurring. That is why I brought it up. Not so much that we hadn't discussed it. think we did almost ad nauseam. But the question is do you want to kick it up
to this next level where it actually enters the indication.
I
agree with Jim. If you say
"for" pregnancy instead of "and" pregnancy, that one word
makes it so that you have the wiggle room that you need to keep it an open shop
and, at the same time, reasonable.
That's all.
DR.
RICE: I think you are leaving a lot of
flexibility because if I was a pharmaceutical company and I had the option, I
would go for just the follicular development and "for pregnancy"
sounds like my secondary endpoint which I am already looking at.
So
I guess I don't distinguish between the two.
I mean, either you are going to look at pregnancy as your outcome by
some measure or you are going to continue to look at follicular
development. If we are going to continue
to look at follicular development, are we really going to be ever distinguish
between Product A versus Product B versus anything else that comes on the
market if they only have to look at follicular development, because we have
pretty much shown that, when you look at the different products, there is not a
great deal of difference in follicular development.
You
would have to decide, are we going to raise the level of rigor here or are we
not.
DR.
GIUDICE: Dr. Stanford?
DR.
STANFORD: It just seems to me the main
indication--and if the FDA staff disagree with that, I would like to know, but
it seems to me they are the same.
DR.
GIUDICE: Dr. Shames?
DR.
SHAMES: The primary endpoint is the
indication. So if we decide that
pregnancy is the primary important endpoint, then it should be the indication.
DR.
GIUDICE: Dr. Layman?
DR.
LAYMAN: I just have a point for
clarification. We said we agreed that
fetal heart beat was the indictor for pregnancy. But, in that Question 8 that says, if we are
not taking live birth or ongoing pregnancy rate, is the way that question
reads. Did we mean--I'm not clear
whether we meant we want to say for pregnancy all of them or just in that
question, I mean, because it is not clear.
I
didn't get the feeling we agreed on what was the best pregnancy to
consider. It just says, if you can't
have enough power for live birth rate or ongoing, which one. And we said heart beat.
DR.
GIUDICE: Right. That was what we had discussed. Now, there seems to be some ambiguity,
though.
DR.
SLAUGHTER: I don't believe so. The question was worded is live birth or
ongoing pregnancy to suggest something further along than gestational sac with
a heart beat. So I think we clearly
understand that that is what we are talking about now, that we want gestational
sac with heart beat.
DR.
GIUDICE: Right.
DR.
LAYMAN: Right. I agree, but does that mean for every study
that is what we are requiring? We are
not requiring live birth or farther on.
That is what I am asking. Did we
agree to that?
DR.
GIUDICE: We agreed to that. Dr. Lewis?
DR.
LEWIS: I thought the only exception was
for Type 1 anovulation where we agreed it would be very difficult to power a
study to look at--okay.
DR.
GIUDICE: Right. Dr. Stanford, you had a comment?
DR.
STANFORD: Sort of the next question; it
is sort of like there is an 8A question that is, if the study cannot be powered
for presence of fetal heartbeat, and that might be the Type 1, then what is an
acceptable outcome in that case. It
sounds like that is the question you are putting on the table.
DR.
LEWIS: I wasn't really putting it on the
table because I thought we had already discussed it. I thought we had already agreed that it
would--ovulation. I'm sorry; follicular
development.
DR.
STANFORD: So, I guess, then the issue is
under what--if we all agree that fetal heart beat is a reasonable standard in
general, then, under what conditions do you accept something else as a main
outcome, something less than that as a main outcome, then, as an
indication. We are saying that Type 1,
WHO Category Type 1, anovulation would be one.
DR.
GIUDICE: Right. Are we all clear on that? Any further discussion? It is amazing we got through all those
questions. I would like to thank
everyone for their participation today.
Tomorrow's session begins at 8:30 in the morning and the discussion will
be NDA 21322 on Luveris. For members of
the committee, please bring your green FDA binding document and your gray
Serono briefing documents.
[Whereupon,
at 4:39 p.m., the meeting was recessed to be resumed at 8:30 a.m., Tuesday,
September 30.]
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