Mixed protocols for the treatment of infertility

Abstract

Methods, uses and products are described that include recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation and menotropins (human menopausal gonadotropin or hMG) for the treatment of infertility in patients aged 35 years or older.

Description

[Technical field]

[0001] The present invention relates to pharmaceutical agents and methods for the treatment of infertility. [Background technology]

[0002] Assisted reproductive technologies (ART), such as in vitro fertilization (IVF), are well known. ART generally requires a phase of controlled ovarian stimulation (COS), in which a cohort of follicles is stimulated to full maturity. Standard COS regimens include the administration of gonadotrophins, such as menotropins (e.g., human menopausal gonadotropin (hMG)) and follicle-stimulating hormone (FSH), alone or in combination with luteinizing hormone (LH) activity, to stimulate multiple follicular development. COS typically requires the administration of a GnRH analog (GnRH agonist) or GnRH antagonist before and / or during stimulation to prevent a premature LH surge that may induce ovulation before the scheduled oocyte collection. The aim of COS is generally to stimulate and mature a large number of follicles and to collect a large number of oocytes for fertilization when ovulation is induced. Generally, the best oocytes are selected for transfer, while other oocytes may be cryopreserved for future use.

[0003] It is believed that COS may entail the risk of ovarian hyperstimulation syndrome (OHSS) if ovarian response is too high, which may lead to the termination of COS cycles and may be life-threatening in severe cases. If it is possible to predict a woman's possible ovarian response to COS, it may be possible to develop personalized or individualized COS protocols. Such personalized protocols may, for example, reduce the risk of OHSS in women who are predicted to have excessive ovarian response to COS and prevent the termination of COS cycles. The level of anti-Mullerian hormone (AMH) directly correlates with the ovarian response to gonadotrophins during COS. Thus, high levels of AMH are a good predictor of excessive ovarian response and an indicator of the risk of OHSS, while low levels of AMH predict poor ovarian response to COS. Other predictors of ovarian response include age, body mass index (BMI), FSH and antral follicle count (AFC).

[0004] In humans, FSH and LH act in concert to stimulate follicle formation and ovulation. Thus, these gonadotropins are typically used in COS to increase the number of oocytes produced in IVF. This concept of FSH-LH combination has led to the widespread use of so-called "mixed protocols" in which simultaneous treatment with hMG and FSH is used for ovarian stimulation. Indeed, COS protocols utilizing both hMG (a source of both FSH and LH activity) and FSH are commonly used in an attempt to obtain higher quality oocytes and embryos and thus higher pregnancy rates compared to the use of recombinant FSH alone. The determination of the stimulation protocol and FSH dosage is typically established by the physician based on various parameters that may include various combinations of the patient's age, weight, and ovarian reserve profile (AMH, AFC, BMI, etc.). However, to date, mixed protocols of follitropin delta (recombinant FSH expressed in a human cell line) and HP-hMG have not been individualized for patients over 35 years of age. Summary of the Invention [Problem to be solved by the invention]

[0005] Therefore, there is a need for improved assisted reproductive technology methods, particularly improved combined hMG and FSH protocols for patients over 35 years of age. [Means for solving the problem]

[0006] In exploratory studies described below, applicants have demonstrated that a combination protocol of individualized dosing of menotropins (human menopausal gonadotropin (hMG)) and recombinant human follicle stimulating hormone (rFSH), including α2,3- and α2,6-sialylated (e.g., follitropin delta), is effective in treating infertility in patients aged 35 years and older based on AMH and body weight.

[0007] The results of the study showed that the use of this combined protocol resulted in a statistically significant increase in the number of good quality, usable blastocysts obtained by the 5th or 6th day of embryo culture, without compromising safety, compared to cycles using follitropin delta alone. The subgroups of patients aged 35-36 and 37-40 years are the ones who are likely to benefit most from the application of this combined regimen. For example, the mean number of good quality blastocysts (adjusted) on the 5th or 6th day after fertilization was 4.03 ± 0.72 in the 35.0-36.9 age group and 4.24 ± 0.62 in the 37.0-40.0 age group, compared to 2.0 ± 2.2 (all age groups) when follitropin delta was used as monotherapy. The incidence of OHSS of any grade was 9.3% (7.4% in the older age groups 35.0-36.9 and 37.0-40.0 years) compared to 2.6% when used as follitropin delta monotherapy. No cases of moderate or severe OHSS were observed, compared to 1.4% of patients when used as follitropin delta monotherapy. Thus, the dosing regimen disclosed herein achieves the desired goal. The proportion of patients who did not require dose adjustment of menotropin (HP-hMG) was 70.83% in the 35.0-36.9 age group and 54.84% in the 37.0-40.0 age group. It is noteworthy that no change in HP-hMG dose was required for this proportion of these patients, as adjustment of the dosing regimen was expected since this was an exploratory study.

[0008] According to some embodiments, a product is provided that includes a menotropin (human menopausal gonadotropin (hMG), e.g., highly purified hMG (HP-hMG)) and recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation, wherein the product is for use in treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) who had a serum AMH level of less than 15 pmol / L prior to treatment or stimulation, wherein the product is administered at a dose of 11-13 μg (e.g., 12 μg) per day of recombinant human FSH containing α2,3- and α2,6-sialylation or an equivalent thereof, and 37.5 IU to 225 IU of HP-hMG per day of menotropin or an equivalent thereof. The dose of hMG may be 75 IU to 225 IU of HP-hMG per day of menotropin, or an equivalent thereof.

[0009] The use may include determining the patient's serum AMH level and administering a dose of recombinant human FSH including α2,3- and α2,6-sialylation and a dose of a menotropin to a patient whose serum AMH level is less than 15 pmol / L. The use may further include determining the patient's serum estradiol (E2) level during treatment or stimulation (e.g., to monitor response to stimulation and subsequently adjust the menotropin dose or, for example, to aid in selection of a trigger drug).

[0010] In some embodiments, the product may be administered from day 1 of stimulation through at least day 5, 6 or 7 of stimulation. From day 6, 7 or 8 of stimulation, the product may be administered at a daily dose of menotropin (while maintaining the dose of rFSH at the dose on day (initiation) 1) that is maintained, increased or decreased based on the patient's serum estradiol (E2) levels on day 5, 6 or 7 of stimulation. Beginning on the 6th, 7th, or 8th stimulation day, the daily dose of menotropins may be reduced to 75 IU (relative to the starting dose) (e.g., reduced by 37.5 IU, reduced by 75 IU, or any amount between 37.5 IU and 75 IU) in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day, or (ii) reduced to zero in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day. From the 6th, 7th or 8th day of stimulation, the daily dose of menotropins may be increased (i) to 150 IU (e.g., 75 IU increment, 150 IU increment, or any amount between 75 IU and 150 IU) in patients whose estradiol (E2) levels were between 750 and 999 pmol / L on the 5th, 6th or 7th day of stimulation, or (ii) to a dose of 225 IU in patients whose estradiol (E2) levels were less than 750 pmol / L on the 5th, 6th or 7th day of stimulation. From the 6th, 7th or 8th day of stimulation, the daily dose of menotropins may be maintained (at the starting dose) in patients whose estradiol (E2) levels were between 1000 and 3000 pmol / L on the 5th, 6th or 7th day of stimulation.

[0011] The use may include the further step of inducing ovulation by administering hCG to a patient who, after stimulation, has 3 or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level of less than 10,000 pmol / L, or administering a GnRH agonist to a patient who, after stimulation, has 3 or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level between 10,000 pmol / L and 15,000 pmol / L; or administering a GnRH agonist to a patient who, after stimulation, has 20 or more follicles, each with a diameter of 12 mm or more, and / or an estradiol (E2) level of 15,000 pmol / mL or more, or 20,000 pmol / mL or more. The dose of hCG administered to the patient may be 5,000 IU to 10,000 IU.

[0012] The use may include the further step of administering a GnRH antagonist starting on day 6 of stimulation.

[0013] The uses may further include one or more or all of the following: retrieving (e.g., harvesting) oocytes, fertilizing (e.g., artificial insemination) oocytes, developing fertilized oocytes to the blastocyst stage, and freezing one or more (or all) blastocysts.

[0014] In some embodiments, the menotropin and the rFSH with α2,3- and α2,6-sialylation are administered separately, e.g., the rFSH with α2,3- and α2,6-sialylation is for morning administration and the menotropin for afternoon or evening administration. In some embodiments, the menotropin and the rFSH with α2,3- and α2,6-sialylation are administered together.

[0015] In some embodiments, the menotropin is highly purified menotropin (HP-hMG). In some embodiments, the rFSH is rFSH where 50-95% of the total sialylation is α2,3-sialylation and 5-50% of the total sialylation is α2,6-sialylation. In some embodiments, the rFSH is rFSH where 80-90% of the total sialylation is α2,3-sialylation and 10-20% of the total sialylation is α2,6-sialylation (e.g., follitropin delta available from Ferring BV).

[0016] In some embodiments, the initial daily dose of menotropins (hMG) is as follows: 75 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is less than 12 μg, 150 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs less than 100 kg, and 225 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs 100 kg or more.

[0017] The use may include the further step of assessing follicular growth by ultrasound examination, for example on the 9th, 10th, 11th, 12th, 13th, 14th day, etc. of stimulation.

[0018] According to some embodiments, a product is provided that includes a menotropin and recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation, wherein the product is for use in treating infertility in a patient 35 years of age or older (e.g., 35-40 years of age, e.g., 35-36 years of age) who had a serum AMH level of 15 pmol / L or greater (e.g., 15-35 pmol / L) prior to treatment or stimulation, and wherein the product is administered at 0.09-0.19 μg of recombinant human FSH containing α2,3- and α2,6-sialylation per kg of patient body weight per day, and 37.5 IU-225 IU of HP-hMG per day of menotropin, or an equivalent dose thereof. The dose of hMG may be 75 IU-225 IU of HP-hMG per day of menotropin, or an equivalent dose thereof.

[0019] The use may include determining the patient's serum AMH level and administering a dose of recombinant human FSH including α2,3- and α2,6-sialylation and a dose of a menotropin to a patient with a serum AMH level of 15 pmol / L or greater (e.g., 15-35 pmol / L). The use may further include determining the patient's serum estradiol (E2) level during treatment or stimulation (e.g., to monitor response to stimulation and subsequently adjust the menotropin dose or, for example, to aid in selection of a trigger drug).

[0020] In some embodiments, the product may be administered from day 1 of stimulation through at least day 5, 6 or 7 of stimulation. From day 6, 7 or 8 of stimulation, the product may be administered at a daily dose of menotropin (while maintaining the dose of rFSH at the dose on day (initiation) 1) that is maintained, increased or decreased based on the patient's serum estradiol (E2) levels on day 5, 6 or 7 of stimulation. Beginning on the 6th, 7th, or 8th stimulation day, the daily dose of menotropins may be reduced to 75 IU (relative to the starting dose) (e.g., reduced by 37.5 IU, reduced by 75 IU, or any amount between 37.5 IU and 75 IU) in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day, or (ii) reduced to zero in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day. From the 6th, 7th or 8th day of stimulation, the daily dose of menotropins may be increased (i) to 150 IU (e.g., 75 IU increment, 150 IU increment, or any amount between 75 IU and 150 IU) in patients whose estradiol (E2) levels were between 750 and 999 pmol / L on the 5th, 6th or 7th day of stimulation, or (ii) to a dose of 225 IU in patients whose estradiol (E2) levels were less than 750 pmol / L on the 5th, 6th or 7th day of stimulation. From the 6th, 7th or 8th day of stimulation, the daily dose of menotropins may be maintained (at the starting dose) in patients whose estradiol (E2) levels were between 1000 and 3000 pmol / L on the 5th, 6th or 7th day of stimulation.

[0021] The use may include the further step of inducing ovulation by administering hCG to a patient who, after stimulation, has 3 or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level of less than 10,000 pmol / L, or administering a GnRH agonist to a patient who, after stimulation, has 3 or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level between 10,000 pmol / L and 15,000 pmol / L; or administering a GnRH agonist to a patient who, after stimulation, has 20 or more follicles, each with a diameter of 12 mm or more, and / or an estradiol (E2) level of 15,000 pmol / mL or more, or 20,000 pmol / mL or more. The dose of hCG administered to the patient may be 5,000 IU to 10,000 IU.

[0022] The use may include the further step of administering a GnRH antagonist starting on day 6 of stimulation.

[0023] The uses may further include one or more or all of the following: retrieving (e.g., harvesting) oocytes, fertilizing (e.g., artificial insemination) oocytes, developing fertilized oocytes to the blastocyst stage, and freezing one or more (or all) blastocysts.

[0024] In some embodiments, the menotropin and the rFSH with α2,3- and α2,6-sialylation are administered separately, e.g., the rFSH with α2,3- and α2,6-sialylation is for morning administration and the menotropin for afternoon or evening administration. In some embodiments, the menotropin and the rFSH with α2,3- and α2,6-sialylation are administered together.

[0025] In some embodiments, the menotropin is highly purified menotropin (HP-hMG). In some embodiments, the rFSH is rFSH where 50-95% of the total sialylation is α2,3-sialylation and 5-50% of the total sialylation is α2,6-sialylation. In some embodiments, the rFSH is rFSH where 80-90% of the total sialylation is α2,3-sialylation and 10-20% of the total sialylation is α2,6-sialylation (e.g., follitropin delta available from Ferring BV).

[0026] In some embodiments, the initial daily dose of menotropins (hMG) is as follows: 75 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is less than 12 μg, 150 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs less than 100 kg, and 225 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs 100 kg or more.

[0027] The use may include the further step of assessing follicular growth by ultrasound examination, for example on the 9th, 10th, 11th, 12th, 13th, 14th day, etc. of stimulation.

[0028] According to some embodiments, a method of treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) who had a serum AMH level of less than 15 pmol / L prior to treatment, the method comprising: identifying a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) who had a serum AMH level of less than 15 pmol / L prior to treatment; administering to the patient human menopausal gonadotropin (hMG), recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylated, wherein the rFSH is administered at a daily dose of 11-13 μg (e.g., 12 μg) of rFSH, or an equivalent thereof, and wherein the hMG is administered at a daily dose of 37.5 IU to 225 IU of highly purified hMH (HP-hMG), or an equivalent thereof. The dose of hMG may be 75 IU to 225 IU of HP-hMG per day of menotropins, or an equivalent dose.

[0029] According to some embodiments, a method of treating infertility in a patient who is 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and has a serum AMH level of less than 15 pmol / L prior to treatment includes identifying a patient who is 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and has a serum AMH level of 15 pmol / L or greater prior to treatment (e.g., between 15 and 35 pmol / L prior to treatment), administering human menopausal gonadotropin (hMG) to the patient, and recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation, where rFSH is administered at a dose of 0.09-0.19 μg rFSH per kg patient body weight per day, or an equivalent dose, and hMG is administered at a dose of 37.5 IU-225 IU highly purified hMG (HP-hMG) per day, or an equivalent dose. The dose of hMG may be 75 IU-225 IU of HP-hMG per day, or an equivalent dose.

[0030] According to some aspects, there is provided a pharmaceutical composition comprising a menotropin (human menopausal gonadotropin or hMG) for use in treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) who has a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L, wherein the pharmaceutical composition is administered in combination with a dose of 37.5 IU to 225 IU HP-hMG per day, or equivalent, of the menotropin and a dose of 11 to 13 μg (e.g., 12 μg) per day, or equivalent, of recombinant human FSH (rFSH) comprising α2,3- and α2,6-sialylation.

[0031] According to some aspects, there is provided a pharmaceutical composition comprising recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation for use in treating infertility in a patient aged 35 years or older (e.g., between 35 and 40 years, e.g., between 35 and 36 years) who had a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L, wherein the pharmaceutical composition is administered in a dose of 11-13 μg (e.g., 12 μg) of recombinant human FSH comprising α2,3- and α2,6-sialylation per day, or an equivalent dose, in combination with a menotropin (human menopausal gonadotropin or hMG) of between 37.5 IU and 225 IU HP-hMG per day, or an equivalent dose.

[0032] According to some embodiments, there is provided a pharmaceutical composition comprising a menotropin (human menopausal gonadotropin or hMG) for use in treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) having a pre-treatment or pre-stimulation serum AMH level of 15 pmol / L or greater (e.g., between 15 and 35 pmol / L), wherein the pharmaceutical composition is administered in combination with the menotropin at a dose of 37.5 IU to 225 IU of HP-hMG per day, or an equivalent dose, and recombinant human FSH comprising α2,3- and α2,6-sialylated at a dose of 0.09 to 0.19 μg per kg of patient body weight per day, or an equivalent dose.

[0033] According to some aspects, there is provided a pharmaceutical composition comprising recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation for use in treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) having a pre-treatment or pre-stimulation serum AMH level of 15 pmol / L or greater (e.g., between 15 and 35 pmol / L), wherein the pharmaceutical composition is administered at a dose of 0.09-0.19 μg of recombinant human FSH comprising α2,3- and α2,6-sialylation per kg of patient body weight per day in conjunction with or equivalent to a dose of menotropin (human menopausal gonadotropin or hMG) of between 37.5 IU and 225 IU of HP-hMG per day. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0034] Applicants have demonstrated that a combination protocol of individualized administration of menotropins (hMG) and recombinant human follicle-stimulating hormone (rFSH), including α2,3- and α2,6-sialylated (e.g., follitropin delta), is effective in treating infertility in patients aged 35 years and older based on AMH and body weight.

[0035] The results of the study showed that the use of this combined protocol resulted in a statistically significant increase in the number of good quality, usable blastocysts obtained by the 5th or 6th day of embryo culture, without compromising safety, compared to cycles using follitropin delta alone. The subgroups of patients aged 35-36 and 37-40 years are the ones who are likely to benefit most from the application of this combined regimen. For example, the mean number of good quality blastocysts (adjusted) on the 5th or 6th day after fertilization was 4.03 ± 0.72 in the 35.0-36.9 age group and 4.24 ± 0.62 in the 37.0-40.0 age group, compared to 2.0 ± 2.2 (all age groups) when follitropin delta was used as monotherapy. The incidence of OHSS of any grade was 9.3% (7.4% in the older age groups 35.0-36.9 and 37.0-40.0 years) compared to 2.6% when used as follitropin delta monotherapy. No cases of moderate or severe OHSS were observed, compared to 1.4% of patients when used as follitropin delta monotherapy. Thus, the dosing regimen disclosed herein achieves the desired goal. The proportion of patients who did not require dose adjustment of menotropin (HP-hMG) was 70.83% in the 35.0-36.9 age group and 54.84% in the 37.0-40.0 age group. It is noteworthy that no change in HP-hMG dose was required for this proportion of these patients, as adjustment of the dosing regimen was expected since this was an exploratory study.

[0036] Thus, provided herein are individualized treatments and dosing regimens designed for use in treating patients aged 35 and older for infertility.

[0037] definition Technical and scientific terms used herein have the meanings commonly understood by those skilled in the art of assisted reproductive technology to which the present invention pertains, unless otherwise defined. Various methodologies known to those skilled in the art are referenced herein. Any suitable materials and / or methods known to those skilled in the art may be used in carrying out the present invention based on the guidance provided herein. However, specific materials and methods are described. Materials, reagents, etc. referred to in the following description and examples are available from commercial sources unless otherwise noted.

[0038] It is to be understood that all definitions and terms defined herein are meant to have the same meaning and purpose in all aspects and embodiments of the present invention, unless expressly stated otherwise.

[0039] As used herein, the singular forms "a," "an," and "the" refer to both the singular and the plural, unless expressly specified to refer to the singular only.

[0040] As used herein, the term "about" means that the number or range so modified is not limited to the exact number or range stated, but rather encompasses a range before or after the recited number or range, as would be understood by one of ordinary skill in the art depending on the context in which the number or range is used. Unless otherwise clear from the context or practice in the art, "about" means up to plus or minus 10% of the particular term.

[0041] As used herein, "ongoing pregnancy" refers to a pregnancy with a viable fetus and a detectable fetal heartbeat at 10-11 weeks gestation, e.g., 8-9 weeks after blastocyst / embryo transfer.

[0042] As used herein, "clinical pregnancy" refers to gestation and a detectable fetal heartbeat during the 5-6 week gestation period, for example, 3-4 weeks after blastocyst / embryo transfer.

[0043] As used herein, the terms "patient" and "subject" and "female" and "woman" are used interchangeably.

[0044] The term "treatment of infertility" includes the treatment of infertility in subjects with tubal or unexplained infertility, for example, the treatment of infertility in subjects with endometriosis, for example, stage I or stage II endometriosis, and / or the treatment of infertility in subjects with a partner with male factor infertility. The product may be for (use in) the treatment of infertility in (and / or for controlled ovarian stimulation) in subjects with endometriosis, for example, stage I or stage II endometriosis, as defined by the American Society for Reproductive Medicine (ASRM) classification system for the various stages of endometriosis (stage IV being the most severe; stage I being the least severe) [American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 1997; 67, 817 821.].

[0045] Serum concentrations of anti-Mullerian hormone (AMH) are now established as a reliable marker of ovarian reserve. Reduced levels of AMH correlate with reduced ovarian response to gonadotrophins during COS. Furthermore, high levels of AMH are a good predictor of excessive ovarian response and a risk indicator of OHSS. According to the present disclosure, in the first (and possibly subsequent) treatment cycles, the individual daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is determined based on the woman's serum AMH concentration and, in some embodiments, her body weight. The recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation dose is based on a recent determination of AMH (i.e., within the past 12 months) as measured, for example, by the ELECSYS® AMH Plus immunoassay (Roche), or similar assays, such as Beckman Coulter's ACCESS AMH Advanced or Fujirebio's UMIPULSE G AMH. Additionally or alternatively, the patient's serum concentration of anti-Mullerian hormone (AMH) may be determined using the Beckmann-Coulter Gen 2 assay as described in Arcee et al., Fertility and Sterility 99:1644-53 (2013), or equivalent AMH levels assessed by another method.

[0046] Subjects were those with a BMI of over 15 and 40 kg / m 2 For example, BMI is more than 17.5 and 38 kg / m 2 For example, BMI is greater than 18 and less than 25 kg / m 2 For example, BMI is 20 or more and 25 kg / m 2 Thus, the products or methods described herein may be of benefit to those with a BMI of greater than 15 and less than 40 kg / m 2 Patients with a BMI of more than 17.5 and less than 38 kg / m 2 Subjects with a BMI of more than 18 and less than 25 kg / m 2 Subjects with a BMI of more than 20 and less than 25 kg / m 2The products or methods described herein may also be used to treat infertility in subjects with a BMI greater than 17.5 and less than 32 kg / m 2 BMI may also be measured by methods known in the art to identify patients for treatment.

[0047] As used herein, the term "follicle" refers to an ovarian follicle, which is a fluid-filled sac that contains an immature egg or oocyte.

[0048] Blastocysts are formed during early human (or other mammalian) development. In humans, blastocyst formation begins about 5 days after fertilization. The use of blastocysts in (IVF) generally involves retrieving (harvesting) a number of oocytes from a woman resulting from a regulated ovarian stimulation cycle, fertilizing (injecting sperm) one or more oocytes, and culturing the fertilized eggs (oocytes) for 5 days to form blastocysts (i.e., allowing the fertilized oocytes to develop to the blastocyst stage); and transferring the blastocyst into the uterus. Embryos are formed during early human (or other mammalian) development. The use of embryos in (IVF) generally involves retrieving (harvesting) a number of oocytes from a woman resulting from a regulated ovarian stimulation cycle, fertilizing (injecting sperm) one or more oocytes, and culturing the fertilized eggs (oocytes) for, for example, 3 days to form embryos (i.e., allowing the fertilized oocytes to develop to the embryo stage); and transferring the embryo into the uterus.

[0049] The term "menotropin" as used herein includes human menopausal gonadotropin (hMG). The term "highly purified menotropin" (HP-hMG) as used herein includes HP-hMG available from Ferring BV under the trademark Menopur®, which contains both follicle stimulating hormone (FSH) and human chorionic gonadotropin (hCG)-driven luteinizing hormone (LH) activity. In some embodiments, the hMG is HP-hMG (e.g., Menopur®) which contains both follicle stimulating hormone (FSH) and human chorionic gonadotropin (hCG)-driven luteinizing hormone (LH) activity.

[0050] The term "GnRH agonist" as used herein includes gonadotropin releasing hormone (GnRH) agonists such as buserelin (e.g., Suprecur®), leuprorelin (e.g., leuprolide acetate, e.g., Leupron®), nafarelin (e.g., Synarel®), and triptorelin (e.g., Trelstar®).

[0051] The term "GnRH antagonist" as used herein refers to gonadotropin-releasing hormone (GnRH) antagonists that block the action of GnRH by competitively blocking the GnRH receptor on the pituitary gonadotropins, thereby inhibiting the production or release of gonadotropins and premature ovulation (release of an egg), and includes gonadotropin-releasing hormone (GnRH) antagonists, such as ganirelix acetate (e.g., Orgalutran®) and cetrorelix acetate (e.g., Cetrotide®).

[0052] According to all embodiments described herein, the recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation may be recombinant FSH from a human cell line, as described in more detail below. In all embodiments, the recombinant FSH containing α2,3- and α2,6-sialylation may be that sold under the trademark Recovel® (follitropin delta) (Ferring BV). In all embodiments, the recombinant FSH may be administered by injection, for example subcutaneous injection.

[0053] As used herein, "treatment day 1", also referred to as "stimulation day 1", refers to the day on which doses of menotropins and recombinant human FSH with α2,3- and α2,6-sialylation are first administered to the patient. Treatment day 1 may occur on day 1, 2 or 3 of the patient's menstrual cycle, e.g., day 2 or 3. In other words, treatment day 1 may be 1, 2 or 3 days, e.g., day 2 or 3, after the patient's menstrual bleeding begins, consistent with the clinical use of the term using GnRH antagonist or GnRH agonist protocols. "During treatment" refers to the day or days on which menotropins and recombinant human FSH with α2,3- and α2,6-sialylation are administered to the patient.

[0054] In the treatments, methods and uses described herein, administration of menotropins and recombinant human FSH, including α2,3- and α2,6-sialylated, may commence on day 1 of treatment and continue for 2-20 days, for example, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 or 20 days. Administration of menotropins and recombinant FSH may commence on day 1 of treatment and continue for 4-20 days, for example, 7-13 days, for example, 9-13 days, for example, 10-13 days, for example, 10-11 days. The dose of recombinant FSH is the same every day and is determined by an established algorithm, as shown below, based on body weight and serum AMH levels, as shown below. However, the daily dose of menotropins may be adjusted for stimulation from the mid-follicular phase, depending on the patient's serum estradiol (E2) levels measured during the mid-follicular phase.

[0055] It will be understood that the mid-follicular phase of stimulation typically occurs 4-6 days after stimulation, for example, on the 5th, 6th, or 7th day of stimulation. Thus, the patient's serum estradiol (E2) level may be measured on the mid-follicular phase of stimulation (e.g., on the 5th, 6th, or 7th day). The adjustment of the daily dose of menotropins may be performed from the day after the patient's serum estradiol (E2) level is measured. Thus, depending on whether the patient's serum estradiol (E2) level is measured on the 5th, 6th, or 7th day of stimulation, the daily dose of menotropins may be adjusted (increased or decreased) or maintained from the 6th, 7th, or 8th day of stimulation.

[0056] As used herein in reference to administration, "equivalent to" means a dose that has the same pharmacological effect as the doses described in the claims or the present specification. For example, a dose of 12 μg per day, or its equivalent, may be the described dose of 12 μg per day, or a pharmacologic equivalent dose such as a dose of 36 μg every 3 days. It is understood that this applies to any dose recited herein.

[0057] treatment In exploratory studies described below, the inventors have demonstrated that a combination protocol of individualized dosing with menotropins (hMG, e.g., HP-hMG) and recombinant human follicle-stimulating hormone (rFSH), including α2,3- and α2,6-sialylated (e.g., follitropin delta), is effective in treating infertility in patients aged 35 years and older based on AMH and body weight.

[0058] The results of the study showed that the use of this combined protocol resulted in a statistically significant increase in the number of good quality, usable blastocysts obtained by the 5th or 6th day of embryo culture, without compromising safety, compared to cycles using follitropin delta alone. The subgroups of patients aged 35-36 and 37-40 years are the ones who are likely to benefit most from the application of this combined regimen. For example, the mean number of good quality blastocysts (adjusted) on the 5th or 6th day after fertilization was 4.03 ± 0.72 in the 35.0-36.9 age group and 4.24 ± 0.62 in the 37.0-40.0 age group, compared to 2.0 ± 2.2 (all age groups) when follitropin delta was used as monotherapy. The incidence of OHSS of any grade was 9.3% (7.4% in the older age groups 35.0-36.9 and 37.0-40.0 years) compared with 2.6% when follitropin delta was used as monotherapy. No cases of moderate or severe OHSS were observed, compared with 1.4% of patients when follitropin delta was used as monotherapy. The proportion of patients who did not require dose adjustment of menotropins (HP-hMG) was 70.83% in the 35.0-36.9 age group and 54.84% in the 37.0-40.0 age group. It is noteworthy that no change in HP-hMG dose was required for this proportion of these patients, since adjustments in the dosing regimen were expected, as this was an exploratory study.

[0059] In a first aspect, a product is provided comprising menotropins (hMG) and recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation, wherein the product is for use in treating infertility in a patient aged 35 years or older (e.g., 35-40 years, e.g., 35-36 years) who has a serum AMH level of less than 15 pmol / L prior to treatment or stimulation, wherein the product is administered at a dose of 11-13 μg (e.g., 12 μg) per day of recombinant human FSH comprising α2,3- and α2,6-sialylation or an equivalent thereof, and at a dose of 37.5 IU to 225 IU HP-hMG per day of menotropins or an equivalent thereof. The dose of hMG may be at a dose of 75 IU to 225 IU HP-hMG per day of menotropins or an equivalent thereof.

[0060] The use may include determining a patient's serum AMH level (e.g., using the automated Elecsys® AMH assay from Roche Diagnostics) and administering a dose of recombinant human FSH containing α2,3- and α2,6-sialylation and a dose of a menotropin to a patient having a serum AMH level below 15 pmol / L.

[0061] The patient may be between 35 and 40 years old or over 40 years old. The use may include determining the age of the patient and administering menotropins (hMG) and recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation to a patient between 35 and 40 years old, such as between 35 and 36 years old. The use may include determining the age of the patient and administering menotropins (hMG) and recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation to a patient over 40 years old.

[0062] This use may further include determining the patient's serum estradiol (E2) level during treatment or stimulation. The patient's serum estradiol (E2) level may be determined for the purposes of monitoring the response to stimulation and subsequently adjusting the daily dose of menotropins and / or for the purposes of selecting an inducer for final follicular maturation as described in more detail below. Serum estradiol (E2) levels may be measured by methods known in the art.

[0063] The product may be administered from day 1 of stimulation through at least day 5, 6 or 7 of stimulation. From day 6, 7 or 8 of stimulation, the product may be administered at a daily dose of menotropin (maintaining the dose of rFSH at the dose on day (initial) 1) that is maintained, increased or decreased based on the patient's serum estradiol (E2) level on day 5, 6 or 7 of stimulation. Thus, the use may include measuring the patient's serum estradiol (E2) level on day 5, 6 or 7, and administering to the patient a daily dose of menotropin (human menopausal gonadotropin or hMG) that is maintained, increased or decreased relative to the starting dose from day 6, 7 or 8 of stimulation.

[0064] Beginning on the 6th, 7th, or 8th stimulation day, the daily dose of menotropins may be reduced to 75 IU (relative to the starting dose) (e.g., by 37.5 IU less, 75 IU less, or any amount between 37.5 IU and 75 IU) in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day, or (ii) reduced to zero in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day. Thus, the use may include measuring the patient's serum estradiol (E2) level on day 5, 6 or 7, and (i) decreasing (relative to the starting dose) a daily dose of menotropin (hMG) to zero in patients whose estradiol (E2) levels exceed 3000 pmol / L on day 5, 6 or 7 of stimulation from day 6, 7 or 8 of stimulation (e.g., decreasing by 37.5 IU, decreasing by 75 IU, or any amount between 37.5 IU and 75 IU).

[0065] Beginning on the 6th, 7th, or 8th stimulation day, the daily dose of menotropins may be increased (i) to 150 IU (relative to the starting dose) in patients whose estradiol (E2) levels were between 750 and 999 pmol / L on the 5th, 6th, or 7th stimulation day (e.g., by a 75 IU increase, a 150 IU increase, or any amount between 75 IU and 150 IU), or (ii) to a dose of 225 IU in patients whose estradiol (E2) levels were less than 750 pmol / L on the 5th, 6th, or 7th stimulation day. Thus, this use may include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering to a patient whose estradiol (E2) level was 750-999 pmol / L on the 5th, 6th or 7th day of stimulation an increased daily dose of menotropins (hMG) of up to 150 IU (e.g., an increase of 75 IU, an increase of 150 IU, or any amount between 75 IU and 150 IU) (relative to the starting dose) starting on the 6th, 7th or 8th day of stimulation. Thus, the use may include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering to patients whose estradiol (E2) level was less than 750 pmol / L on the 5th, 6th or 7th day of stimulation an increased daily dose of menotropin (hMG) to 225 IU from the 6th, 7th or 8th day of stimulation.

[0066] From the 6th, 7th or 8th day of stimulation, the daily dose of menotropins may be maintained (at the starting dose) in patients whose estradiol (E2) levels on the 5th, 6th or 7th day of stimulation were between 1000-3000 pmol / L. This use may thus include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering a dose of 37.5 IU to 225 IU HP-hMG per day, or an equivalent dose, of menotropins from the 6th, 7th or 8th day of stimulation to patients whose estradiol (E2) levels on the 5th, 6th or 7th day of stimulation were between 1000-3000 pmol / L. Thus, this use may include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering a menotropin at a dose of 75 IU to 225 IU HP-hMG per day, or an equivalent dose, from the 6th, 7th or 8th day of stimulation to patients whose estradiol (E2) level on the 5th, 6th or 7th day of stimulation is between 1000 and 3000 pmol / L.

[0067] The use may comprise the further step of inducing ovulation by administering hCG to a patient who, after stimulation, has three or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level of less than 10,000 pmol / L, or administering a GnRH agonist to a patient who, after stimulation, has three or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level between 10,000 pmol / L and 15,000 pmol / L; or administering a GnRH agonist to a patient who, after stimulation, has 20 or more follicles, each with a diameter of 12 mm or more, and / or an estradiol (E2) level of 15,000 pmol / mL or more, or 20,000 pmol / mL or more. The dose of hCG administered to the patient may be between 5,000 IU and 10,000 IU or between 150 and 500 μg of recombinant hCG, for example 250 μg of recombinant hCG. The use may include the further step of administering a GnRH antagonist starting on day 6 of stimulation.

[0068] The uses may further include one or more or all of the following: retrieving (e.g., harvesting) oocytes, fertilizing (e.g., artificial insemination) oocytes, developing fertilized oocytes to the blastocyst stage, and freezing one or more (or all) blastocysts.

[0069] The menotropin and rFSH with α2,3- and α2,6-sialylation may be administered separately, e.g., the rFSH with α2,3- and α2,6-sialylation may be for morning administration and the menotropin for afternoon or evening administration, or the menotropin and rFSH with α2,3- and α2,6-sialylation may be administered simultaneously.

[0070] In some embodiments, the menotropin is highly purified menotropin (HP-hMG). In some embodiments, the rFSH is rFSH where 50-95% of the total sialylation is α2,3-sialylation and 5-50% of the total sialylation is α2,6-sialylation. In some embodiments, the rFSH is rFSH where 80-90% of the total sialylation is α2,3-sialylation and 10-20% of the total sialylation is α2,6-sialylation (e.g., follitropin delta available from Ferring BV).

[0071] In some embodiments, the initial daily dose of menotropins (hMG) is as follows: 75 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is less than 12 μg, 150 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs less than 100 kg, and 225 IU when the daily dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs 100 kg or more.

[0072] The use may include the further step of assessing follicular growth by ultrasound examination, for example on the 9th, 10th, 11th, 12th, 13th, 14th day, etc. of stimulation.

[0073] In a second aspect, a product is provided comprising a menotropin and recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation, wherein the product is for use in treating infertility in a patient aged 35 years or older (e.g., 35-40 years, e.g., 35-36 years) who had a serum AMH level of 15 pmol / L or greater (e.g., 15-35 pmol / L) prior to treatment or stimulation, and wherein the product is administered at 0.09-0.19 μg of recombinant human FSH comprising α2,3- and α2,6-sialylation per kg of patient body weight per day, and 37.5 IU-225 IU of HP-hMG per day of menotropin, or an equivalent dose thereof. The dose of hMG may be 75 IU-225 IU of HP-hMG per day of menotropin, or an equivalent dose thereof.

[0074] The use may include determining a patient's serum AMH level (e.g., using the automated Elecsys® AMH assay from Roche Diagnostics) and administering a dose of recombinant human FSH containing α2,3- and α2,6-sialylation and a dose of a menotropin to a patient with a serum AMH level of 15 pmol / L or greater (e.g., 15-35 pmol / L).

[0075] The patient may be between 35 and 40 years old or over 40 years old. The use may include determining the age of the patient and administering menotropins (hMG) and recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation to a patient between 35 and 40 years old, such as between 35 and 36 years old. The use may include determining the age of the patient and administering menotropins (hMG) and recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation to a patient over 40 years old.

[0076] This use may further include determining the patient's serum estradiol (E2) level during treatment or stimulation. The patient's serum estradiol (E2) level may be determined for the purposes of monitoring the response to stimulation and subsequently adjusting the daily dose of menotropins and / or for the purposes of selecting an inducer for final follicular maturation as described in more detail below. Serum estradiol (E2) levels may be measured by methods known in the art.

[0077] The product may be administered from day 1 of stimulation through at least day 5, 6 or 7 of stimulation. From day 6, 7 or 8 of stimulation, the product may be administered at a daily dose of menotropin (maintaining the dose of rFSH at the dose on day (initial) 1) that is maintained, increased or decreased based on the patient's serum estradiol (E2) level on day 5, 6 or 7 of stimulation. Thus, the use may include measuring the patient's serum estradiol (E2) level on day 5, 6 or 7, and administering to the patient a daily dose of menotropin (human menopausal gonadotropin or hMG) that is maintained, increased or decreased relative to the starting dose from day 6, 7 or 8 of stimulation.

[0078] Beginning on the 6th, 7th, or 8th stimulation day, the daily dose of menotropins may be reduced to 75 IU (relative to the starting dose) (e.g., by 37.5 IU less, 75 IU less, or any amount between 37.5 IU and 75 IU) in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day, or (ii) reduced to zero in patients with estradiol (E2) levels greater than 3000 pmol / L on the 5th, 6th, or 7th stimulation day. Thus, the use may include measuring the patient's serum estradiol (E2) level on day 5, 6 or 7, and (i) decreasing (relative to the starting dose) a daily dose of menotropin (hMG) to zero in patients whose estradiol (E2) levels exceed 3000 pmol / L on day 5, 6 or 7 of stimulation from day 6, 7 or 8 of stimulation (e.g., decreasing by 37.5 IU, decreasing by 75 IU, or any amount between 37.5 IU and 75 IU).

[0079] Beginning on the 6th, 7th, or 8th stimulation day, the daily dose of menotropins may be increased (i) to 150 IU (relative to the starting dose) in patients whose estradiol (E2) levels were between 750 and 999 pmol / L on the 5th, 6th, or 7th stimulation day (e.g., by a 75 IU increase, a 150 IU increase, or any amount between 75 IU and 150 IU), or (ii) to a dose of 225 IU in patients whose estradiol (E2) levels were less than 750 pmol / L on the 5th, 6th, or 7th stimulation day. Thus, the use may include measuring the patient's serum estradiol (E2) level on day 5, 6 or 7, and administering to a patient whose estradiol (E2) level was between 750 and 999 pmol / L on day 5, 6 or 7 of stimulation, (i) an increased daily dose of menotropins (hMG) of up to 150 IU (relative to the starting dose) (e.g., an increased 75 IU, an increased 150 IU, or any amount between 75 IU and 150 IU) beginning on day 6, 7 or 8 of stimulation. Thus, the use may include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering to patients whose estradiol (E2) level was less than 750 pmol / L on the 5th, 6th or 7th day of stimulation an increased daily dose of menotropin (hMG) to 225 IU from the 6th, 7th or 8th day of stimulation.

[0080] From the 6th, 7th or 8th day of stimulation, the daily dose of menotropins may be maintained (at the starting dose) in patients whose estradiol (E2) levels on the 5th, 6th or 7th day of stimulation were between 1000-3000 pmol / L. This use may thus include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering a dose of 37.5 IU to 225 IU HP-hMG per day, or an equivalent dose, of menotropins from the 6th, 7th or 8th day of stimulation to patients whose estradiol (E2) levels on the 5th, 6th or 7th day of stimulation were between 1000-3000 pmol / L. Thus, this use may include measuring the patient's serum estradiol (E2) level on the 5th, 6th or 7th day of stimulation, and administering a menotropin at a dose of 75 IU to 225 IU HP-hMG per day, or an equivalent dose, from the 6th, 7th or 8th day of stimulation to a patient whose estradiol (E2) level on the 5th, 6th or 7th day of stimulation is 1000 to 3000 pmol / L.

[0081] The use may comprise the further step of inducing ovulation by administering hCG to a patient who, after stimulation, has three or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level of less than 10,000 pmol / L, or administering a GnRH agonist to a patient who, after stimulation, has three or more follicles, each with a diameter of 17 mm or more, and an estradiol (E2) level between 10,000 pmol / L and 15,000 pmol / L; or administering a GnRH agonist to a patient who, after stimulation, has 20 or more follicles, each with a diameter of 12 mm or more, and / or an estradiol (E2) level of 15,000 pmol / mL or more, or 20,000 pmol / mL or more. The dose of hCG administered to the patient may be between 5,000 IU and 10,000 IU or between 150 and 500 μg of recombinant hCG, for example 250 μg of recombinant hCG. The use may include the further step of administering a GnRH antagonist starting on day 6 of stimulation.

[0082] The uses may further include one or more or all of the following: retrieving (e.g., harvesting) oocytes, fertilizing (e.g., artificial insemination) oocytes, developing fertilized oocytes to the blastocyst stage, and freezing one or more (or all) blastocysts.

[0083] The menotropin and rFSH with α2,3- and α2,6-sialylation may be administered separately, e.g., the rFSH with α2,3- and α2,6-sialylation may be for morning administration and the menotropin for afternoon or evening administration, or the menotropin and rFSH with α2,3- and α2,6-sialylation may be administered simultaneously.

[0084] In some embodiments, the menotropin is highly purified menotropin (HP-hMG). In some embodiments, the rFSH is rFSH where 50-95% of the total sialylation is α2,3-sialylation and 5-50% of the total sialylation is α2,6-sialylation. In some embodiments, the rFSH is rFSH where 80-90% of the total sialylation is α2,3-sialylation and 10-20% of the total sialylation is α2,6-sialylation (e.g., follitropin delta available from Ferring BV).

[0085] In some embodiments, the initial dose of menotropin (hMG) is as follows: 75 IU when the dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is less than 12 μg, 150 IU when the dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs less than 100 kg, and 225 IU when the dose of recombinant human follicle stimulating hormone (rFSH) with α2,3- and α2,6-sialylation is 12 μg and the patient weighs 100 kg or more.

[0086] The use may include the further step of assessing follicular growth by ultrasound examination, for example on the 9th, 10th, 11th, 12th, 13th, 14th day, etc. of stimulation.

[0087] In a further aspect, a method of treating infertility in a patient aged 35 years or older (e.g., between 35 and 40 years, e.g., between 35 and 36 years old) who had a serum AMH level of less than 15 pmol / L prior to treatment, comprising identifying a patient aged 35 years or older (e.g., between 35 and 40 years, e.g., between 35 and 36 years old) who had a serum AMH level of less than 15 pmol / L prior to treatment, administering to the patient human menopausal gonadotropin (hMG), recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation, wherein the rFSH is administered at a dose of 11-13 μg (e.g., 12 μg) per day of rFSH, or an equivalent dose, and wherein the hMG is administered at a dose of 37.5 IU to 225 IU per day of highly purified hMG (HP-hMG), or an equivalent dose. The dose of hMG may be 75 IU to 225 IU of HP-hMG per day of menotropins, or an equivalent dose.

[0088] According to some embodiments, a method of treating infertility in a patient who is 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and has a serum AMH level of less than 15 pmol / L prior to treatment includes identifying a patient who is 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and has a serum AMH level of 15 pmol / L or greater prior to treatment (e.g., between 15 and 35 pmol / L prior to treatment), administering human menopausal gonadotropin (hMG) to the patient, and administering the patient a steroid hormone (HSG) supplement. ), and recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation, where rFSH is administered at a dose of 0.09-0.19 μg / kg of patient body weight per day, or an equivalent dose, and hMG is administered at a dose of 37.5 IU-225 IU of highly purified hMG (HP-hMG) per day, or an equivalent dose. The dose of hMG may be 75 IU-225 IU of HP-hMG per day, or an equivalent dose.

[0089] It will be appreciated that the above methods of treatment may be used in accordance with any aspect of the invention disclosed herein.

[0090] In a further aspect, there is provided a pharmaceutical composition comprising a menotropin (hMG) for use in treating infertility in a patient aged 35 years or older (e.g., between 35 and 40 years old, e.g., between 35 and 36 years old) who has a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L, wherein the pharmaceutical composition is administered in combination with a menotropin at a dose of 37.5 IU to 225 IU HP-hMG per day, or an equivalent dose, and a recombinant human FSH (rFSH) containing α2,3- and α2,6-sialylation at a dose of 11 to 13 μg (e.g., 12 μg) per day, or an equivalent dose.

[0091] In a further aspect, there is provided a pharmaceutical composition comprising recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation for use in treating infertility in a patient aged 35 years or older (e.g., between 35 and 40 years, e.g., between 35 and 36 years) who had a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L, wherein the pharmaceutical composition is administered at a dose of 11-13 μg (e.g., 12 μg) of recombinant human FSH comprising α2,3- and α2,6-sialylation per day, in conjunction with or at an equivalent dose of menotropins (hMG) at a dose of 37.5 IU to 225 IU HP-hMG per day.

[0092] In a further aspect, there is provided a pharmaceutical composition comprising menotropins (hMG) for use in treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) who has a pre-treatment or pre-stimulation serum AMH level of 15 pmol / L or greater (e.g., between 15 and 35 pmol / L), wherein the pharmaceutical composition is administered in combination with a menotropin at a dose of 37.5 IU to 225 IU HP-hMG per day, or an equivalent dose, and recombinant human FSH (rFSH) containing α2,3- and α2,6-sialylation at a dose of 0.09 to 0.19 μg per kg of patient body weight per day, or an equivalent dose.

[0093] In a further aspect, there is provided a pharmaceutical composition comprising recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation for use in treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) having a pre-treatment or pre-stimulation serum AMH level of 15 pmol / L or greater (e.g., between 15 and 35 pmol / L), wherein the pharmaceutical composition is administered at a dose of 0.09-0.19 μg of recombinant human FSH comprising α2,3- and α2,6-sialylation per kg of patient body weight per day, in conjunction with or at an equivalent dose of menotropins (hMG) at a dose of 37.5 IU to 225 IU HP-hMG per day.

[0094] It will be appreciated that the above pharmaceutical compositions represent components of products according to other aspects of the invention and may be used in accordance with any aspect of the invention disclosed herein.

[0095] Menotropins and recombinant FSH and rFSH compositions The methods and products described herein use recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation. FSH contains a 92 amino acid alpha subunit, common to other glycoprotein hormones LH and chorionic gonadotropin (CG), and a 111 amino acid beta subunit unique to FSH that confers the hormone's biological specificity (Pierce and Parsons, 1981). Each subunit is post-translationally modified by the addition of complex carbohydrate residues. Both subunits have two sites for N-linked glycan attachment, amino acid 52 and 78 for the alpha subunit, and amino acid 7 and 24 for the beta subunit (Rathnam and Saxena, 1975, Saxena and Rathnam, 1976). Thus, FSH is glycosylated to about 30% by mass (Dias and Van Roey. 2001. Fox et al. 2001).

[0096] Glycosylation of rFSH products reflects the range of glycosyltransferases present in the host cell system. Commercially available rFSH products derived from engineered Chinese hamster ovary cells (CHO cells) have a more limited range of glycosylation than the natural product. Examples of reduced glycan heterogeneity found in CHO cell-derived rFSH include the absence of bisected glucosamine, and reduced content of core fucosylation and acetyllactosamine extensions (Hard et al., 1990). Furthermore, CHO cells can only add sialic acid at α2,3 linkages (Kagawa et al., 1988, Takeuchi et al., 1988, Svensson et al., 1990); therefore, CHO cell-derived rFSH contains only α2,3-linked sialic acid and no α2,6-linked sialic acid. Thus, rFSH derived from CHO cells differs from naturally produced FSH (e.g., human pituitary / serum / urinary FSH), which contains glycans with a mixture of α2,3- and α2,6-linked sialic acids (i.e., α2,3- and α2,6-sialylated), with a predominance of α2,3-linked sialic acids.

[0097] The applicants have developed rFSH from a human cell line, which is the subject of International Patent Application No. PCT / GB2009 / 000978 (published as WO 2009 / 127826A) and which has also been approved by the European Commission as REVOKELLE® (follitropin delta) (also known as FE999049). This recombinant FSH was produced with a mixture of both α2,3-linked and α2,6-linked sialic acids (i.e., α2,3- and α2,6-sialylated) by engineering a human cell line to express both rFSH and α2,3-sialyltransferase. The amino acid sequence of recombinant FSH from human cell lines (e.g., follitropin delta / FE999049), the subject of International Patent Application No. PCT / GB2009 / 000978, published as WO 2009 / 127826A, is the native human FSH sequence, but the product has a different glycosylation pattern. The expressed product is highly acidic and has a mixture of both α2,3-linked sialic acid and α2,6-linked sialic acid (i.e., α2,3- and α2,6-sialylated), the latter being provided by endogenous sialyltransferase activity. It has been found that the sialic acid linkage, α2,3- or α2,6-, can have a dramatic effect on the biological clearance of FSH. Thus, REVOKELLE® (follitropin delta / FE999049) is more biologically relevant than CHO cell-derived recombinant products that have only α2,3-linked sialic acid (Kagawa et al., 1988; Takeuchi et al., 1988; Svensson et al., 1990) and can have a reduced sialic acid content (Ulloa-Aguirre et al. 1995; Andersen et al. 2004).

[0098] Thus, recombinant FSH containing α2,3- and α2,6-sialylation used in accordance with the methods and products described herein may be produced or expressed in a human cell line, such as the PER.C6® cell line. Recombinant FSH may be produced or expressed in a PER.C6® cell line, a PER.C6® derived cell line, or a modified PER.C6® cell line. Recombinant FSH produced or expressed in a PER.C6® cell line will contain some α2,6 linked sialic acid (α2,6 sialylation) provided by endogenous (cell line) sialyltransferase activity and some α2,3 linked sialic acid (α2,3 sialylation) provided by endogenous sialyltransferase activity. The cell line may be modified with α2,3 sialyltransferase. The cell line may be modified with α2,6 sialyltransferase. Alternatively, or additionally, the recombinant FSH may comprise α2,6-linked sialic acid (α2,6 sialylation) provided by endogenous sialyltransferase activity (of the cell line). As used herein, the term "human-derived recombinant FSH" refers to recombinant FSH that is produced or expressed in a human cell line (e.g., recombinant FSH made by genetically engineering a human cell line).

[0099] The recombinant FSH used in the methods and products described herein may comprise α2,3- and α2,6-sialylation. The recombinant FSH for use according to the invention may have between 1% and 99% of the total sialylation being α2,3-sialylation. The recombinant FSH for use according to the invention may have between 1% and 99% of the total sialylation being α2,6-sialylation. The recombinant FSH may have between 1% and 50% of the total sialylation being α2,6-sialylation and between 50% and 99% of the total sialylation being 2,3-sialylation. For example, between 80% and 95%, such as between 80% and 90%, such as between 82% and 89%, such as between 85% and 89% of the total sialylation being α2,3-sialylation. For example, 5%-20%, such as 10%-20%, such as 11%-18%, such as 11%-15% of the total sialylation may be α2,6-sialylated. In one example, the recombinant FSH is 5%-20% of the total sialylation and 80%-95% of the total sialylation is 2,3-sialylated. In another example, the recombinant FSH is 50%-80% of the total sialylation and 20%-50% of the total sialylation is 2,3-sialylated.

[0100] As used herein, "sialylation" refers to the amount of sialic acid residues present in the recombinant FSH carbohydrate structure. Consistent with usage in the art, α2,3-sialylation refers to sialylation at the 2,3 position and α2,6 sialylation refers to sialylation at the 2,6 position. Thus, "% of total sialylation may be α2,3 sialylation" refers to the % of the total number of sialic acid residues present in FSH (or hCG) that are sialylated at the 2,3 position. The term "% of total sialylation that is α2,6-sialylation" refers to the % of the total number of sialic acid residues present in FSH (or hCG) that are sialylated at the 2,6 position.

[0101] In all embodiments, rFSH may be present as a single isoform or as a mixture of isoforms.

[0102] Recombinant FSH and hMG may be formulated into well-known compositions for any route of drug administration, e.g., oral, rectal, parenteral, transdermal (e.g., patch technology), intravenous, intramuscular, subcutaneous (e.g., for subcutaneous injection), intracisternal, intravaginal, intraperitoneal, topical (powders, ointments or drops) or as buccal or nasal sprays. Exemplary compositions include pharma- ceutically acceptable carriers, e.g., aqueous solutions, non-toxic excipients, e.g., salts and preservatives, buffers, etc., as described, inter alia, in Remington's Pharmaceutical Sciences fifteenth edition (Matt Publishing Company, 1975), pages 1405-1412 and 1461-87, and in national formulary XIV fourth edition (American Pharmaceutical Association, 1975). For example, recombinant FSH, compositions or pharmaceutical compositions may be formulated for injection, e.g., subcutaneous injection.

[0103] Examples of suitable aqueous and non-aqueous pharmaceutical carriers, diluents, solvents or vehicles include water, ethanol, polyols (e.g., glycerol, propylene glycol, polyethylene glycol, and the like), carboxymethylcellulose and suitable mixtures thereof, vegetable oils (e.g., olive oil), and injectable organic esters such as ethyl oleate.

[0104] The composition may also include additives such as, but not limited to, preservatives, wetting agents, emulsifiers, surfactants and dispersing agents. Antibacterial and antifungal agents may be included to prevent the growth of microorganisms, and include, for example, m-cresol, benzyl alcohol, parabens, chlorobutanol, phenol, sorbic acid, and the like. When a preservative is included, benzyl alcohol, phenol and / or m-cresol are preferred; however, the preservative is by no means limited to these examples. In addition, it may be desirable to include isotonic agents, such as sugars, sodium chloride, amino acids, and the like.

[0105] For example, the composition or medicament may include recombinant FSH and one or more of polysorbate 20, L-methionine, phenol, and arginine hydrochloride. Such compositions may be formulated for injection, such as subcutaneous injection. For example, the rFSH composition or medicament may be a Recobel® formulation (follitropin delta with excipients phenol, polysorbate 20, L-methionine, sodium sulfate decahydrate, disodium phosphate dodecahydrate, phosphoric acid [concentrated, to adjust pH], sodium hydroxide [to adjust pH], and water for injection).

[0106] Injectable preparations can be sterilized, for example, by filtration through a bacteria-retaining filter, or by incorporating a sterilizing agent in the form of a sterile solid composition that can be dissolved or dispersed in sterile water or other sterile injectable medium immediately before use.Injectable preparations can be provided in any suitable container, for example, vial, pre-filled syringe, injection cartridge, etc.

[0107] The recombinant FSH, composition or agent can be formulated for single use or multiple use (multiple doses). When the recombinant FSH, composition or agent is formulated for multiple use, it typically includes one or more preservatives. When a preservative is included, benzyl alcohol, phenol or m-cresol are preferred, but the preservative is by no means limited to these examples. The single or multiple use formulated composition or agent may further include an amino acid or a combination of amino acids. Typically, the amino acid is arginine, for example, added as arginine or more typically as arginine hydrochloride.

[0108] The recombinant FSH, composition or medicament may be included in a container such as a vial, a pre-filled cartridge (eg, for single or multiple use), or an injection device, eg, a multi-dose "pen".

[0109] The recombinant FSH, composition or pharmaceutical composition may be a formulation (eg, an injectable formulation) comprising rFSH.

[0110] The recombinant FSH, composition or agent can be provided in any suitable package. For example, the composition or agent can include multiple containers (e.g., prefilled syringes or vials) containing FSH. The syringes or vials can be packaged in blister packages or other means that maintain sterility. Any composition or agent can optionally include instructions for using the FSH formulation.

[0111] The pH and exact concentrations of the various components of the pharmaceutical composition are adjusted according to routine practice in the art. th ed. In a typical embodiment, the recombinant FSH, composition or agent is provided as a composition for parenteral administration. General methods for preparing parenteral formulations are known in the art and are described in REMINGTON; THE SCIENCE AND PRACTICE OF PHARMACY, supra, pp. 780-820. Parenteral compositions can be provided in liquid formulations or as solids that are mixed with a sterile injection medium immediately prior to administration. Parenteral compositions may be provided in dosage unit form for ease of administration and uniformity of dosage.

[0112] In a further aspect there is provided the use of recombinant follicle stimulating hormone (FSH) in the manufacture of a medicament for use as described herein.

[0113] Further aspects are described in the following examples, which are not limiting in any way.

[0114] The menotropins used in the methods and products described herein, such as human menopausal gonadotropin (hMG), may be highly purified menotropins. The term "highly purified menotropins" as used herein includes HP-hMG available from Ferring BV under the trademark Menopur®, which contains both follicle stimulating hormone (FSH) and human chorionic gonadotropin (hCG)-driven luteinizing hormone (LH) activity. In some examples, the hMG used in the methods and products described herein is HP-hMG (e.g., Menopur®) which contains both follicle stimulating hormone (FSH) and human chorionic gonadotropin (hCG)-driven luteinizing hormone (LH) activity. In some examples, the hMG used in the methods and products described herein is Menopur® HP-hMG product, which is typically provided as a lyophilized powder or pellet that is mixed with a sterile diluent (e.g., 0.9% sodium chloride for injection) prior to use. Menopur® is a powder and solvent solution for injection. In addition to hMG, the ingredients of Menopur® are lactose, polysorbate 20, hydrochloric acid, sodium chloride, sodium hydroxide, and water for injection. EXAMPLES

[0115] The following examples use Recobel® (follitropin delta), a recombinant FSH expressed in the PER.C6® cell line engineered by the methods disclosed in WO 2013 / 020996 and WO 2009 / 127826, and Menopur®, a highly purified menotropin containing both follicle stimulating hormone (FSH) and human chorionic gonadotropin (hCG)-driven luteinizing hormone (LH) activity (HP-hMG).

[0116] The Marketing Authorisation Holder for Recobel® and Menopur® is Ferring Pharmaceuticals A / S of Kay Fiskers Plads 11, 2300 Copenhagen S, Denmark and Recobel® is available in the UK from Ferring Pharmaceuticals of Drayton Hall, Church Road, West Drayton, UB7 7PS, UK.

[0117] The active substance in Recobel® is follitropin delta (FE999049). Recobel® is highly sialylated, including α2,3-sialylated and α2,6-sialylated, with approximately 85-90% of the total sialylated being α2,3-sialylated and approximately 10-15% of the total sialylated being α2,6-sialylated.

[0118] Recobel® is a clear, colorless solution for injection. Each milliliter of solution contains 33.3 micrograms of follitropin delta in each milliliter of solution. Other ingredients are phenol, polysorbate 20, L-methionine, sodium sulfate decahydrate, disodium phosphate dodecahydrate, concentrated phosphoric acid, sodium hydroxide, and water for injection.

[0119] The active substance in Menopur® is human menopausal gonadotrophin (HMG).

[0120] Menopur® is a powder and solvent solution for injection. Other ingredients are lactose, polysorbate 20, hydrochloric acid, sodium chloride, sodium hydroxide, and water for injection. Menopur® (e.g., Menopur® 75 IU Injection, Menopur® 1200 IU powder and solvent for injection solution) are available in the UK from Ferring Pharmaceuticals Limited of Drayton Hall, Church Road, West Drayton, UB7 7PS, UK.

[0121] Example 1: Menopur and Recovel Combination Study (MARCS): An Exploratory Study Evaluating the Efficacy of Individualized Doses of Follitropin Delta and Highly Purified Human Menopausal Gonadotropin (HP-hMG) for Controlled Ovarian Stimulation Introduction The MARCS trial was part of the Evidence-based Stimulation Trial with Human Recombinant Follicle-Stimulating Hormone in Europe and Rest of World 1 (ESTHER-1) trial (Nyboe Andersen A, Nelson SM, Fauser BC, Garcia-Velasco JA, Klein BM, Arce JC; ESTHER-1 study group. Individualized versus conventional ovarian stimulation for in vitro fertilization: a multicenter, randomized, controlled, assessor-blinded, phase 3 noninferiority trial. Fertil Steril. 2017 We aimed to assess the mean number of good quality blastocysts obtained on days 5 and 6, and the proportion of women with ovarian hyperstimulation syndrome (OHSS), following treatment with an individualized dosing regimen of follitropin delta and highly purified human menopausal gonadotrophin (HP-hMG) compared with treatment with an individualized dose of follitropin delta used as monotherapy in (Feb;107(2):387-396).

[0122] method The study was a multicenter, open-label, single-cohort study with external (synthetic) control evaluating the efficacy and safety of personalized dosing of follitropin delta and HP-hMG in combination ("mixed protocol"). Patients were enrolled at four study sites in Canada. The study protocol was approved by local regulatory authorities and an independent ethics committee. The study was conducted in accordance with the principles of the Declaration of Helsinki, the International Conference on Harmonization Guidelines for Good Clinical Practice, and local regulatory requirements. All participants provided written informed consent before undergoing any study-related procedures.

[0123] Study Participants Women enrolled in the study were aged 18-40 years, had a confirmed diagnosis of infertility (including endometriosis stage I / II or tubal factor) and were being treated with their first IVF / intracytoplasmic sperm injection (ICSI) cycle. Additional inclusion criteria were regular menstrual cycles of 24-35 days, presence of both ovaries, use of ejaculated sperm (fresh or frozen) for insemination, and early follicular phase FSH serum concentration <10 IU / L. Main exclusion criteria were endometriosis stage III / IV, high risk of OHSS (AMH >35 pmol / L), history of recurrent miscarriage defined as three or more consecutive miscarriages, and use of hormonal therapy (except thyroid medication) in the last menstrual cycle before study enrollment.

[0124] Test procedure All patients enrolled in the study were treated with a fixed, personalized daily subcutaneous dose of follitropin delta (Recobel®, Ferring Pharmaceuticals A / S) based on body weight and serum AMH levels (Table 1), as determined by an established algorithm, the subject of International Patent Application No. PCT / EP2012 / 065507, published as WO 2013 / 020996. Serum AMH measurements were performed in a central laboratory (CReATe Fertility Centre) using the automated Elecsys AMH immunoassay (Roche) and were measured within 12 months prior to the start of ovarian stimulation.

[0125] [Table 1]

[0126] The dose is rounded to the nearest 0.33 micrograms to match the dosage markings on the injection pen.

[0127] HP-hMG (Menopur®, Ferring Pharmaceuticals A / S) was administered in combination with follitropin delta to all patients at an initial dose personalized according to the patient's weight and the calculated follitropin delta dose.

[0128] The initial daily doses of HP-hMG were as follows: If the dose of follitropin delta was less than 12 µg, the dose was 75 IU. If the daily dose of follitropin delta is 12 µg and the patient weighs less than 100 kg, the dose is 150 IU. The daily dose of follitropin delta is 12 µg and for patients weighing 100 kg or more, it is 225 IU.

[0129] Gonadotropin therapy was initiated on day 2 of the menstrual cycle. Gonadotropin-releasing hormone (GnRH) antagonists were initiated on day 6 of stimulation and continued for the remainder of the stimulation period. Responses to stimulation were monitored by serum estradiol (E2) levels and vaginal ultrasound.

[0130] As this was an exploratory study, adjustments to the dosing regimen were expected. Stimulation adjustments were limited to HP-hMG and were allowed only from day 6 of stimulation. The dose of HP-hMG could be increased or decreased depending on the E2 level on day 6 of stimulation, regardless of follicular development, with a maximum daily dose of 225 IU. Dose adjustments of HP-hMG were performed according to the schedule described in Table 2.

[0131] [Table 2]

[0132] Follicular maturation was finally induced when 3 or more follicles reached a diameter of 17 mm. The choice of induction agent was based on pre-induction serum E2 levels as follows: hCG 5,000–10,000 IU if E2 was <10,000 pmol / L, and GnRH agonist 0.2 mg (triptorelin acetate, decapeptyl; Ferring Pharmaceuticals) if E2 was ≥10,000 pmol / L. A total freezing strategy was employed in cases of hyperresponse, defined as serum E2 levels ≥15,000 pmol / L on the day of induction or ≥20 follicles ≥12 mm. Cycles were terminated in cases of poor follicular development, defined as <3 follicles ≥17 mm by day 20.

[0133] Oocyte retrieval was performed 36±2 hours after the start of final follicular maturation. Oocytes were fertilized by IVF or ICSI using sperm ejaculated from the partner or donor. All embryos were cultured until day 5 or 6. All fresh embryo transfers were performed on day 5 of culture and were all single embryo transfers.

[0134] Excess blastocysts were cryopreserved for future use if they were ≥3BB according to the Gardner classification. Daily intramuscular progesterone was prescribed for luteal phase support. Adverse events were recorded from the time of signing the informed consent until the end of the study, defined as day 6 of blastocyst formation. If an adverse event was reported during a study visit, the study team followed up until the adverse event was resolved.

[0135] Test results The primary endpoint of the study was the number of good quality (>3BB) blastocysts (usable blastocysts) on days 5 and 6. Secondary objectives were ovarian response, embryology, and safety of the regimen. Ovarian response and embryo development included duration of stimulation, total dose of follitropin delta, percentage of patients induced with GnRH agonist, mean number of mature oocytes obtained, mean number of embryos on day 3, and percentage of day 3 embryos that developed into usable blastocysts on days 5 or 6 (attrition rate). Safety was performed by assessing the incidence and severity of early and late onset moderate to severe OHSS classified according to the Golan system (see Table 3).

[0136] [Table 3]

[0137] result The study used a single-cohort, open-label design with an external (synthetic) control as the comparator. Patients enrolled in the ESTHER-1 study who were treated with personalized doses of follitropin delta served as comparators. Table 4 shows the primary and secondary endpoints by cohort of MARCS compared to ESTER-1, and Table 5 shows the primary and secondary endpoints of the MARCS cohort distributed by age group.

[0138] [Table 4]

[0139] [Table 5]

[0140] [Table 6]

[0141] Tables 4 and 5 demonstrate that the use of the mixed protocol described herein results in a statistically significant increase in the number of good quality, usable blastocysts obtained by embryo culture day 5 or 6, without compromising safety, compared to cycles using follitropin delta as monotherapy.

[0142] The subgroups of patients aged 35-36 and 37-40 years are those who are likely to benefit most from the application of the combination regimen. For example, the mean number of good quality blastocysts (adjusted) on the 5th-6th day after fertilization was 4.03±0.72 in the 35.0-36.9 age group and 4.24±0.62 in the 37.0-40.0 age group, compared to 2.0±2.2 (all age groups) when follitropin delta was used as monotherapy. These results suggest that women aged 35 years or older will have the highest number of oocytes obtained with the combination treatment protocol described herein and evaluated in this study.

[0143] The incidence of OHSS of any grade was 9.3% (7.4% in the older age groups 35.0-36.9 years and 37.0-40.0 years) compared to 2.6% when follitropin delta was used as monotherapy. No cases of moderate or severe OHSS were observed, compared to 1.4% of patients when follitropin delta was used as monotherapy. Thus, the dosing regimen described herein achieves the desired goal.

[0144] The proportion of patients who did not require dose adjustment of menotropin (HP-hMG) was 70.83% in the 35.0-36.9 age group and 54.84% in the 37.0-40.0 age group. It is noteworthy that no change in HP-hMG dose was required for this proportion of patients, as adjustments in the dosing regimen were expected as this was an exploratory study.

[0145] conclusion Optimization of the ovarian response in IVF by using a combined protocol of individualized administration of both follitropin delta and HP-hMG results in a statistically significant increase in the number of good quality usable blastocysts on day 5 or 6, with an increased risk of only mild OHSS that did not require medical intervention or hospitalization. The subgroups of patients aged 35-36 and 37-40 years are those who appear to benefit most from the application of this combined regimen.

Claims

1. 1. A product comprising a menotropin (human menopausal gonadotropin or hMG) and recombinant human follicle stimulating hormone (rFSH) containing α2,3- and α2,6-sialylation; for use in the treatment of infertility in patients aged 35 years or older (e.g., between 35 and 40 years, e.g., between 35 and 36 years) who have a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L; wherein the product is administered at a dose of 11-13 μg (e.g., 12 μg) per day of said recombinant human FSH containing α2,3- and α2,6-sialylation or an equivalent dose, and at a dose of 37.5 IU to 225 IU HP-hMG per day of said menotropin or an equivalent dose.

2. 2. The product for use of claim 1, wherein said use comprises determining said serum AMH level in said patient and administering said dose of recombinant human FSH comprising α2,3- and α2,6-sialylation and said dose of a menotropin to a patient having a serum AMH level less than 15 pmol / L.

3. 1. A product comprising a menotropin and a recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation; for use in the treatment of infertility in a patient aged 35 years or older (e.g. between 35 and 40 years, e.g. between 35 and 36 years) having a serum AMH level of 15 pmol / L or greater prior to treatment or stimulation; and administered at a dose of 0.09 to 0.19 μg of recombinant human FSH comprising α2,3- and α2,6-sialylation per kg of body weight of said patient per day, or an equivalent dose, and at a dose of 37.5 IU to 225 IU of HP-hMG (e.g. 75 IU) of said menotropin per day, or an equivalent dose.

4. 4. The product for use of claim 3, wherein said use comprises determining said serum AMH level of said patient and administering said dose of recombinant human FSH comprising α2,3- and α2,6-sialylation and said dose of a menotropin to a patient having a serum AMH level of 15 pmol / L or greater.

5. The use comprises increasing serum estradiol (E ２ 5. A product for use according to any one of claims 1 to 4, comprising the further step of measuring levels of

6. The product for use according to any one of claims 1 to 5, which is administered from the first day of stimulation to at least the fifth, sixth or seventh day of stimulation.

7. From the 6th, 7th or 8th day of stimulation, the patient's serum estradiol (E ２ 7. The product for use according to claim 6, wherein the daily dose of menotropin is maintained, increased or decreased based on the level of menotropin.

8. Starting on the sixth, seventh or eighth day of stimulation, the daily dose of menotropin is increased by: (i) administering estradiol (E ２ (ii) decrease (relative to starting dose) to 75 IU (e.g., decrease by 37.5 IU, decrease by 75 IU, or decrease by any amount between 37.5 IU and 75 IU) in patients with estradiol (E) levels greater than 3000 pmol / L; or (iii) decrease (relative to starting dose) estradiol (E) levels on the 5th, 6th, or 7th stimulation day. ２ 8. The method of claim 7, wherein the method reduces erythrocyte sedimentation rate (ESR) levels to zero in patients with erythrocyte sedimentation rate (ESR) levels above 3000 pmol / L.

9. Starting on the sixth, seventh or eighth day of stimulation, the daily dose of menotropin is increased by: (i) administering estradiol (E ２ In patients with levels between 750 and 999 pmol / L, increase (relative to the starting dose) to 150 IU (e.g., an increment of 75 IU, an increment of 150 IU, or any increment between 75 IU and 150 IU); or (ii) increase estradiol (E ２ 8. The method of claim 7, wherein the dose is increased to 225 IU (relative to the starting dose) in patients with levels below 750 pmol / L.

10. From the 6th, 7th or 8th day of stimulation, the daily dose of menotropin is increased by the 5th, 6th or 7th day of stimulation. ２ 8. The method of claim 7, wherein the level is maintained in a patient having a serum creatine phosphate level of between 1000 and 3000 pmol / L.

11. The above use, after stimulation, produces three or more follicles each having a diameter of 17 mm or more, and ２ administering hCG to patients with estradiol (E) levels below 10,000 pmol / L; or administering hCG to patients with 3 or more follicles, each measuring 17 mm or greater in diameter, after stimulation and estradiol (E ２ administering a GnRH agonist to a patient who has a GnRH (GnRH) level between 10,000 pmol / L and 15,000 pmol / L; or administering a GnRH agonist to a patient who has 20 or more follicles, each with a diameter of 12 mm or more, and / or an estradiol (E ２ 11. The product for use according to any one of claims 1 to 10, comprising the further step of inducing ovulation by administering a GnRH agonist to a patient having a GnRH level of ≧15,000 pmol / mL or ≦20,000 pmol / mL.

12. 12. The product for use according to claim 11, wherein the dose of hCG administered to the patient is between 5,000 IU and 10,000 IU.

13. A product for use according to any one of claims 6 to 12, wherein said use comprises the further step of administering a GnRH antagonist from day 6 of stimulation.

14. The use includes retrieving (e.g., harvesting) oocytes, fertilizing (e.g., artificial insemination) the oocytes, developing the fertilized oocytes to the blastocyst stage, and 14. A product for use according to any one of claims 1 to 13, further comprising freezing of one or more (or all) blastocysts.

15. 15. A product for use according to any one of claims 1 to 14, wherein the menotropin and the rFSH with α2,3- and α2,6-sialylation are administered separately, e.g. the rFSH with α2,3- and α2,6-sialylation is for administration in the morning and the menotropin for administration in the afternoon or evening.

16. 16. A product for use according to any one of claims 1 to 15, wherein the menotropin and rFSH comprising α2,3- and α2,6-sialylation are administered together.

17. The product for use according to any one of claims 1 to 16, wherein the menotropin is highly purified menotropin (HP-hMG).

18. 18. A product for use according to any one of claims 1 to 17, wherein said rFSH is an rFSH in which 50-95% of the total sialylation is α2,3-sialylation and 5-50% of the total sialylation is α2,6-sialylation.

19. 19. Product for use according to any one of claims 1 to 18, wherein the daily dose of menotropin (human menopausal gonadotropin or hMG) is 75 IU when the daily dose of said recombinant human Follicle Stimulating Hormone (rFSH) containing α2,3- and α2,6-sialylation is less than 12 μg; 150 IU when the daily dose of said recombinant human Follicle Stimulating Hormone (rFSH) containing α2,3- and α2,6-sialylation is 12 μg and the patient weighs less than 100 kg; 225 IU when the daily dose of said recombinant human Follicle Stimulating Hormone (rFSH) containing α2,3- and α2,6-sialylation is 12 μg and the patient weighs 100 kg or more.

20. 20. A product for use according to any one of claims 1 to 19, wherein said use comprises a further step of assessing follicular growth by ultrasound examination, for example on the 9th, 10th, 11th, 12th, 13th, 14th etc. day of stimulation.

21. 1. A method of treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and having a pre-treatment serum AMH level of less than 15 pmol / L, comprising: Identifying patients who are 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and have a pre-treatment serum AMH level of less than 15 pmol / L; Administering to the patient human menopausal gonadotropin (hMG) and recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation, wherein the rFSH is administered at a dose of 11-13 μg (e.g., 12 μg) of the rFSH per day, or an equivalent dose, and the hMG is administered at a dose of 37.5 IU to 225 IU of highly purified hMG (HP-hMG) per day, or an equivalent dose.

22. 1. A method of treating infertility in a patient 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and having a pre-treatment serum AMH level of less than 15 pmol / L, comprising: Identifying patients who are 35 years of age or older (e.g., between 35 and 40 years of age, e.g., between 35 and 36 years of age) and have a pre-treatment serum AMH level of 15 pmol / L or greater; 1. A method comprising administering to the patient human menopausal gonadotropin (hMG) and recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation, wherein the rFSH is administered at a dose of 0.09-0.19 μg of the rFSH per kg of the patient's body weight per day, or an equivalent dose, and the hMG is administered at a dose of 37.5 IU to 225 IU of highly purified hMG (HP-hMG) per day, or an equivalent dose.

23. 1. A pharmaceutical composition comprising a menotropin (human menopausal gonadotropin or hMG) for use in the treatment of infertility in patients aged 35 years or older (e.g., 35-40 years, e.g., 35-36 years) who have a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L, wherein said menotropin at a dose of 37.5 IU to 225 IU HP-hMG per day, or an equivalent dose, is administered together with a dose of 11-13 μg (e.g., 12 μg) per day of recombinant human FSH (rFSH) containing α2,3- and α2,6-sialylation, or an equivalent dose.

24. 1. A pharmaceutical composition comprising recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation for use in the treatment of infertility in patients aged 35 years or older (e.g. 35-40 years, e.g. 35-36 years) who have a pre-treatment or pre-stimulation serum AMH level of less than 15 pmol / L, wherein said recombinant human FSH comprising α2,3- and α2,6-sialylation is administered at a dose of 11-13 μg (e.g. 12 μg) per day or an equivalent dose, together with a menotropin (human menopausal gonadotropin or hMG) at a dose of 37.5 IU to 225 IU HP-hMG per day or an equivalent dose.

25. 1. A pharmaceutical composition comprising a menotropin (human menopausal gonadotropin or hMG) for use in the treatment of infertility in a patient aged 35 years or older (e.g., between 35 and 40 years, e.g., between 35 and 36 years) who has a pre-treatment or pre-stimulation serum AMH level of 15 pmol / L or greater, wherein said menotropin is administered at a dose of 37.5 IU to 225 IU HP-hMG per day, or an equivalent dose, together with recombinant human FSH containing α2,3- and α2,6-sialylation at a dose of 0.09-0.19 μg per kg body weight of said patient per day, or an equivalent dose.

26. 1. A pharmaceutical composition comprising recombinant human follicle stimulating hormone (rFSH) comprising α2,3- and α2,6-sialylation for use in the treatment of infertility in a patient aged 35 years or older (e.g. between 35 and 40 years, e.g. between 35 and 36 years) having a pre-treatment or pre-stimulation serum AMH level of 15 pmol / L or greater, wherein said recombinant human FSH comprising α2,3- and α2,6-sialylation is administered at a dose of 0.09-0.19 μg / kg body weight of said patient per day in combination with a menotropin (human menopausal gonadotropin or hMG) at a dose of 37.5 IU to 225 IU HP-hMG per day or an equivalent dose.

Images