UTILISATION D'ANTAGONISTES DE LA LH-RH DANS LE TRAITEMENT DES TROUBLES DE L'INFERTILITE

LHRH-ANTAGONISTS IN THE TREATMENT OF FERTILITY DISORDERS

Abrégé français

Méthode de traitement des troubles de l'infertilité comportant les étapes suivantes : 1) administration d'un antagoniste de la LH-RH, de préférence Cetrorelix, en quantité suffisante pour supprimer la LH endogène, mais non la sécrétion de FSH, et 2) induction d'une croissance folliculaire par administration de gonadotrophine exogène. La suppression sélective de la LH permet à la sécrétion de la FSH de se maintenir au niveau naturel S et ne perturbe donc pas le développement individuel des oestrogènes. L'antagoniste de la LH-RH peut être administré par voie sous-cutanée en dose unique ou double de l'ordre de 1 à 10 mg, de préférence 2 à 6 mg. Dans une posologie à doses multiples, l'antagoniste de la LH-RH peut être administré par voie sous-cutanée à raison de 0,1 à 0.5 mg par jour. L'administration commence entre le 1er et le 10e jour du cycle, de préférence entre le 4e et le 8e, et l'ovulation peut être induite entre le 9e et le 20e jour par administration de LH rec., de LH-RH native, d'agonistes de la LH-RH ou de HCG. On peut aussi administrer de la LH rec., de la LH-RH native ou un agoniste de la LH-RH pour éviter de stimuler la phase lutéale en neutralisant les effets négatifs de la HCG.

Abrégé anglais

A method of treating infertility disorders by 1) administering an
LH-RH antagonist, preferably Cetrorelix, in amounts to selectively
suppress endogenous LH but not FSH secretion and 2) inducing follicle
growth by administration of exogenous gonadotropin. The selective
suppression OF LH allows FSH secretion to be at natural level S thereby not
affecting individual estrogen development. The LH-RH antagonist can be
given as a single or dual subcutaneous dose in the range of 1 mg to 10 mg,
preferably 2 mg - 6 mg. In multiple dosing posology, LH-RH antagonist
can be administered subcutaneously in an amount in the range of 0.1 to 0.5
mg of LH-RH antagonist/day. LH-RH antagonist is applied starting cycle
day 1 to 10, preferably on day 4 to 8, and ovulation can be induced between
day 9 and 20 of the menstruation cycle by administering rec. LH, native
LH-RH, LH-RH agonist or by HCG. In addition rec. LH, native LH-RH or
LH-RH agonist can be given to avoid hyperstimulation syndrome and
native LH-RH or a LH-RH agonist can be administered to avoid luteal
phase stimulation by neutralizing the negative effects of HCG.

Revendications

11
THE EMBODIMENTS OF THE INVENTION IN WHICH AN EXCLUSIVE PROPERTY OR
PRIVILEGE IS CLAIMED ARE DEFINED AS FOLLOWS:
1. A use of a luteinizing hormone releasing hormone (LHRH) antagonist for the
manufacture
of a medicament for the production of a fertilizable oocyte within a program
of controlled
ovarian stimulation for assisted reproduction techniques (COS/ART), wherein
the
medicament is adapted as a unit dosage form comprising 0.25 mg of the LHRH
antagonist to
be used in the absence of follicular growth stimulation by an exogenous
gonadotropin, and
wherein the LHRH antagonist is selected from the group consisting of
Cetrorelix, Ganirelix,
Antarelix, Antide, Azaline B, Ramorelix, A-76154, NalGLu, D-23980 and D-24824.
2. The use of claim 1, wherein the medicament is adapted for subcutaneous
injection.
3. The use of claim 1 or 2, wherein the LHRH antagonist is Cetrorelix.
4. A pharmaceutical composition comprising a luteinizing hormone releasing
hormone
(LHRH) antagonist and a pharmaceutically acceptable carrier for the production
of a
fertilizable oocyte within a program of controlled ovarian stimulation for
assisted reproduction
techniques (COS/ART), wherein the composition is adapted as a unit dosage form
comprising 0.25 mg of the LHRH antagonist to be used in the absence of
follicular growth
stimulation by an exogenous gonadotropin, and wherein the LHRH antagonist is
selected
from the group consisting of Cetrorelix, Ganirelix, Antarelix, Antide, Azaline
B, Ramorelix, A-
76154, NalGLu, D-23980 and D-24824.
5. The composition of claim 4, wherein the medicament is adapted for
subcutaneous
injection.
6. The composition of claim 4 or 5, wherein the LHRH antagonist is Cetrorelix.

Description

CA 02200541 2004-08-25
LHRH - ANTAGONISTS IN THE TREATMENT
OF FERTILITY DISORDERS
Field of the Invention
The field of invention is directed to the use of LHRH-antagonists to
treat male and female fertility disorders.
Background of the Invention
The reasons for unsuccessful attempts to establish pregnancy can be
2 0 attributed equally to male and female fertility disorders. Today many
different assisted reproduction techniques are available. These techniques
are used to induce multiple and synchronous follicular growth and thereby
obtain fertilizable oocytes.
The current standard treatment is to induce multiple follicular
2 5 development by administering high doses of HMG (Human Menopausal
Gonadotropin). This results in ovarian hyperstimulation. Upon reaching a
suitable degree of oocyte maturation using these techniques, ovulation is
induced by the administration of HCG (Human Chorion-Gonadotropin) in
order to obtain a sufficient number of oocytes. During this time, the clinic-
30 infrastructure preparation can begin. Preparation includes recovery of
oocytes by abdominal or transvaginal puncture, intracorporal or
extracorporal fertilization of oocytes by different techniques and embryo
replacement into the uterus. Routinely, beginning pregnancy is supported
by additional administrations of HCG or progesterone. Today this

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treatment is applied to clinical conditions of male and female infertility.
Complications that are frequently observed during the
hyperstimulation procedure are:
A: premature surges of luteinizing hormone (LH) at a premature
maturation state with a rupture of the follicles that induced a subsequent
cancellation of the treatment occurring in about 25% of the patients; and B:
ovarian hyperstimulation syndromes induced by exogenous gonadotropins
which in severe cases require hospitalization and are life-threatening.
In order to avoid premature LH-surges, today LHRH-agonists are
used as a comedication. By continued administration of these drugs, a
complete suppression of endogenous gonadotropins is achieved by
desensitization of pituitary cells and down-regulation of their receptors.
Subsequently, the gonadotropin levels can be controlled by exogenous
injection and the pituitary is refractory to the stimulation of LH-release by
increasing levels of estradiol. Disadvantages are 1) a long treatment period
until the suppression and down-regulation occur; 2) estrogen withdrawal
symptoms; 3) disturbance of the normal menstrual cycle; 4) the need for
frequent hormone determinations in order to evaluate the time of onset of
suppression; and 5) high dose HMG treatment is needed for ovarian
2 0 stimulation.
The pathogenesis of hyperstimulation syndrome is not completely
understood, but is thought to be associated with the use of HCG for
ovulation induction and luteal phase support.
One recent approach involves the use of the LHRH antagonist
2 5 Cetrorelix (INN). In first clinical trials, short term treatment with
Cetrorelix resulted in a complete avoidance of premature LH surges during
stimulated cycles and the need for HMG. Due to the immediate

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suppression of gonadotropins by this antagonist, the unwanted stimulatory
phase and also the withdrawal of estrogen produced by the agonists was
avoided. The duration of treatment was also significantly shortened. In
addition, it was shown that a single injection of an antagonist, given in the
mid-follicular phase, would adequately suppress premature LH surges.
SUMMARY OF THE INVENTION
Despite the improvements described above, these treatment
modalities suffered the drawback of treating the patients with the highest
possible dose of exogenous gonadotropins to hyperstimulate multiple
follicular development which results in some severe adverse events.
The current invention reduces the severe adverse events, improves
patient compliance and reduces costs. Recent data obtained with Cetrorelix
also demonstrates additional surprising new advantages for the treatment of
male and female infertility.
In animal experiments and clinical studies with Cetrorelix, it was
possible to induce an arrest of the normal, unstimulated follicular growth
by multiple or single injections. These effects were observed with
extremely low dosage levels. These low dosage levels present new
possibilities for manipulating the time of ovulation during a normal, not
exogenous gonadotropin-stimulated cycle, without affecting the viability of
the growing follicle. In case of inadequate follicular growth related to
treatment with LHRH-antagonists, low dose and short term administration
of gonadotrophin or other trophic compounds will compensate for these
2 5 effects. Subsequently, by stopping the LHRH-antagonist treatment, it is
possible to let the normal ovulation occur or to induce ovulation by
exogenous manipulation, if necessary. Ovulation induction was induced by

CA 02200541 2010-06-03
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the administration of standard HCG or by administration of LHRH and/or
LHRH agonistic analogs, such as recombinant LH, native LHRH, and HCG.
These described treatment alternatives are a departure from existing
protocols, since they are possible only if preceded by treatment for LH-
surge-control with an LHRH-antagonist. In animal and clinical studies
with Cetrorelix it was shown that the responsiveness of the pituitary to
LHRH or agonistic analogs is preserved under these conditions of
treatment. Without this treatment, the pituitary cannot respond after
agonistic pretreatment for LH-surge control due to receptor down-
regulation. In addition, the possible use of ovulation inducing agents other
than HCG results in a reduced incidence of ovarian hyperstimulation
syndrome.
On the basis of the described results, for the first time it is possible
to use normal, non-gonadotropin-stimulated cycles for assisted
reproduction techniques, including sperm injections, by determining the
time of ovulation by the duration and dose of Cetrorelix given. Especially
in conjunction with the method of ICSI (Intra-Cytoplasmatic-Sperm-
Injection) this antagonist-dependent treatment modality facilitates the
inclusion of in-(sub-)fertile males into this kind of fertility treatment. Due
to the direct injection of male gametes capable for fertilization, this method
has a high success rate and hence, allows the harvest of only one follicle for
fertilization. In addition, the use of LHRH-antagonists like Cetrorelix in
the described manner relieves the patient from severe ovarian
hyperstimulation and significantly reduces the costs of a treatment cycle.
LHRH-antagonists of the invention can be used in combination with
assisted reproduction techniques, especially the extracorporal fertilization,
e.g. the in-vitro fertilization and the sperm injection techniques.

CA 02200541 2010-06-03
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Compounds with the desired LHRH-antagonistic activity include a
TM
LHRH-analog such as Ganirelix, Antarelix, Amide, Azaline B, Ramorelix,
A-761 54, Nal-Glu, 88-88, in particular -Cetrorelix or a structure-truncated
peptide with LHRH-antagonistic activity or a peptideomimetic with
LHRH-antagonistic activity, for example D-23980 and D-24824, or a
bicyclic (1-4.4-10) LHRH analog with antagonistic activity.
LHRH-antagonists of the invention can be subcutaneously
administered in dosage amounts of about 0.001-0.2 mg/kg-
Both dosing schedules demonstrate the prevention of any premature
LH surge. After both posologies good fertilization rates have been obtained
with good follicle and oocytes quality. Pregnancy rates are good after both
treatments. To date, a total of 44 healthy babies are born following both
treatments.
The single dose regimen requires only one single injection of 3 ml.
This has to be regarded as being convenient for the patient. So far, duration
of effect to prevent a premature LH surge is up to 6.5 days. After 3 days,
monitoring of hormones is advisable in order to apply a second injection in
case of a low responder to HMG with prolonged administration of HMO,
and if an increase of LH values is seen.
The multiple dose schedule requires daily injections of 1 ml for 3 to
7 days, sometimes up to 10 or 14 days. This is not as convenient as a single
or dual injection. On the other hand, regular monitoring of the hormones is
not required and the application of HCG could even be extended if required
in rare cases.
It is an embodiment that the LH-RH antagonist in the single or dual dosage
regimen
is started on cycle day 1 to 10, cycle day 4 to 8 or cycle day 6 to 10.
In summary, from a medical point of view, both treatments comparable efficacy,
safety and practicability, therefore each gynecologist should have the
possibility to decide
upon the dosing schedule with respect

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to the situation observed in each single patient.
The results of a phase II clinical trial are shown in Table I.
A total of 235 patients were treated.
No premature LH surge was seen in any patient undergoing
COS/ART treated with either multiple doses of 0.25 mg or higher or a
single dose of 3 mg or higher. During multiple dosing, the mean days of
Cetrorelix application is 6 days. 25 babies were born by the end of May
1996 (7 following multiple doses; 18 following single/dual doses).

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Table I
Cetrorelix
Development Controlled Ovarian Stimulation (COS/ART)
Subj. Nos. Phase Dose/Day Posology
(mg) (days)
14 II/proof concept 3 3-10
19 11/proof concept 1 3-10
11 II/proof concept 0.5 3-10
32 lU 0.5 3-7/14
30 dose finding/ 0.25 min. effect. dose
(28) minimal effective dose 0.10 no effect. dose
21 11/proof concept 5 1 or 2
18 II/proof concept 3 1 or 2
32 11/dose finding/ 3 min. effective dose 1
30 minimal effective dose 2 no effect. Dose 1
SUM 235 71 pregnancies (30%) 44 healthy
Phase 11 finished 16 pregnancies (ongoing) children
The main advantages in controlled ovarian stimulation (COS/ART) with
Cetrorelix are:
1. New therapeutic principle
a) Prevention of premature LH-surges
b) Uniform and continuous follicular synchronization
c) Uniform and continuous estradiol development
d) Very low LH-values for optimal follicular development

-8-
2. Short term treatment of 3 to 7 days to max 14 days
a) Short-term exposure during follicular development
b) Low medication exposure during follicular development
3. No flare-up but immediate hormonal response
4. No pretreatment for 14 to 21 days before start of HMG needed
5. Fits well into normal menstrual cycle with
a) No modification of physiological menstrual cycle pattern or
b) No hormonal withdrawal syndromes before stimulation
6. No or only ultrashort-term residual effects after ovulation induction
7. No residual effects during and following embryo transfer
8. No ovarian cyst formation before start of stimulation
9. Reduction of HMG.
Table II (flow chart) shows an example on a typical treatment start
and duration of HMG and Cetrorelix in patients to undergo controlled
ovarian superovulation for ART.

2200541,
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2 2 0 0
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Example
238 patients were treated with Cetrorelix by subcutaneous injection
of Cetrorelix Acetat-Lyophilisat.
134 patients were treated with multiple doses and 104 patients with
single or dual doses. The multiple doses are 0.25 mg/day or higher. The
single dose was 3 mg or higher. No premature LH surge was seen in any
patient undergoing controlled ovarian superovulation for assisted
reproduction technology (COS/ART) treated with these dosages. Multiple
doses were applied for 3 to a maximum of 10 days dependent on follicular
development.
As a result 71 pregnancies were obtained = 30.0%
38 of 134 following the multiple does regimen = 28.4%
33 of 104 following the single/dual dosage regimen = 31.7%
Following treatment 44 babies were born that means 15 following
multiple does and 29 following single/dual does. 16 pregnancies are still
ongoing. Figure 1 shows this in particular
Figure 1 shows an absolute prevention of any premature LH surge.
Furthermore, FSH secretion is maintained at a natural level and therefore
the individual estrogen development is not affected.