ART products and usage TOTAL CYCLE CONTROL Leong Ka Hong MDCM DSc Adjunct Professor Dept of Obs/Gyn McGill University Montreal Canada Specialist Reproductive.

ART products and usage

TOTAL CYCLE CONTROL

Leong Ka Hong MDCM DSc

Adjunct Professor Dept of Obs/Gyn

McGill University Montreal Canada

Specialist Reproductive Medicine Hong Kong

Shanghai 14 May 2004

BRAVELLETM

Highly purified urofollitropinFerring Pharmaceuticals

BRAVELLE

• Highly purified urinary FSH

• NOT a generic Metrodin-HP

• NDA in USFDA

• Indications– Ovulation induction– IVF

BRAVELLE vs Metrodin-HP

BRAVELLE Metrodin-HP

Urine sources Argentina (BSA no risk) Italy (BSA high risk)

FSH dosage/amp IU 75 75

Active ingredient purity (% of total protein)

95% 95%

LH residual (% of total protein or IU)

≤ 2% < 0.1 IU

Purification technology Multiple Ion exchange chromatography

Immunochromatograph (monoclonal anti-FSH)

BRAVELLE vs rFSH

• Sources– Bravelle: pooled human urine– rFSH: rFSH containing culture media with

Fetal Bovine serum

• Purification steps– Bravelle: ion exchange chromatography – rFSH: immuno-chromatography

• Other industrial steps– More or less the same

Risks of Prion Contamination

• Bravelle:– Low possibility, from pooled human urine– Urine from Argentina (CJD low risk)

• rFSH– Possibility 1, Fetal Bovine Serum used in culturing CHO cells

(FBS were from US or Canadian sources in which BSE cases found recently)

– Possibility 2, immunopurification step which employed monoclonal FSH antibody. Mab was also made from cultured cells which grown in media with FBS

Dickey et al., 2003

Dickey et al., 2003

Dickey et al., 2003

Dickey et al., 2003

• Conclusions– Bravelle(R) and Follistim(R) had comparable

efficacy in controlled ovarian hyperstimulation in women undergoing IVF-ET. There were no differences in the nature or number of adverse events between the treatment groups although Bravelle(R) injections were reported to be significantly less painful.

Feigenbaum et al., 2001

Feigenbaum et al., 2001

Feigenbaum et al., 2001

Feigenbaum et al., 2001

• Conclusion

• The efficacy and treatment toleration of Bravelle™, a new, highly purified, human-derived FSH, is comparable to that of recombinant follitropin beta in patients undergoing ovulation induction.

BRAVELLE HKIVF DATA

# of OPU 19 11 <40, 8 ≥40

Total dose 887 (46) Range 26 – 68

# of eggs retrieved 193 MTII 126 (65%)

MTI 38 (20%)

Fertilization rate % 59%

Total # of Embryos Transfer 54 Average # of ET 2.8/opu

# of pregnancy 9

Pregnancy rate %/opu 47%

Implantation rate 22.6%

Progesterone

Sites of production• Corpus luteum• Placenta

Functions• Increase endometrial receptivity• Maintain pregnancy

Oral vs Vaginal Administration

Oral• Liver first-pass metabolism• Low serum level (low bioavailability)• Side effects due to metabolites

Vaginal• Avoids liver first-pass metabolism• Fewer systemic side effects• Low serum level• Uterine first-pass effect• High tissue conc. (High bioavailability)

Progesterone - Natural vs Synthetic

Natural Synthetic

Androgenic activity

Teratogenicity

Lipoprotein metabolism

Beneficial to BV Half-life 4 – 8 min. -

Structure & Synthesis of Progesterone

Plasma Progesterone Levels

• Follicular phase: <2 ng/ml

• Luteal phase: 2 - 20 ng/ml

• 1st trimester of pregnancy: ~10 - 40 ng/ml

• Near term: ~ 100 - 200 ng/ml

• 15% drop: 1 hr after a meal & in the early morning

Endometrin®

Product Description• Progesterone vaginal tablet (with applicator)• Developed in Israel• Micronized progesterone (100 mg)

Indication• Progesterone supplementation or

replacement in cases such as treatment of infertile women and IVF

Endometrin Characteristics

• Prolong release for 12 hours (100 mg)– Bid

• Uterine 1st pass effects– Ensures maximal uterine/endometrial exposure

• Advanced formulation– Easy administration with specific applicator– Without messy discharge– Unaltered vaginal pH – minimized risks of infection

Progesterone supplement

N=15 ENDO UTRO CYCLO

1 supp BD 48.6ng 34ng 62.2ng

2 supp BD 55.7ng 87ng 54.7ng

General Principles of combined pituitary suppression / ovarian stimulation therapy (From Insler and Lunenfeld)

The structure of GnRH agonistic analogues

Outcome results according to type of protocol and gonadotrophin used (n=13426)

Crude pregnancy rates using different GnRH agonist protocols in IVF (From Daya)

18.920.5

23.2

0

5

10

15

20

25

30

Short Ultrashort Long

GnRH-a protocols

Cli

nica

l pre

gnan

cy p

er c

ycle

sta

rt (

%)

Schematic representation of different protocols using GnRH agonists in combination with gonadotrophins for ovarian stimulation in IVF

Trade names, plasma half-lives, relate potency, route of administration and recommended dose for the clinically available gonadotrophins

Structure of GnRH agonists

Modifications of natural GnRHto have GnRH agonistic properties

1 2 43 65 98 107

pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2

activation of the GnRH receptor

regulation of GnRHreceptoraffinity

regulation ofbiologic activity

Action of GnRH agonists

LH + FSH

post-receptor-cascade

GnRH - receptor

GnRH

GnRH - agonistflare up effect

Downregulation

pituitary suppression

Premature LH surge

• Poor quality

• No fertilization or very poor pregnancy rate

• Cancel egg retrieval

5-20%

All cycles treated in 1980’s

non pregnant pregnant

1.0

1.5

2.0

2.5

Comparing LH values two days before HCG iniection for oocyte maturation berween the pregnant and the non-

pregnant group

n=35 n=22

mean 2.2 (SD 1.3)

mean 1.5 (SD 0.8)

p=0.03

Results of first application of GnRH-agonists in the long protocol

• 11 patients eligible for IVF• GnRH agonist s.c. (buserelin) started at day of

menstruation or one day before• ovarian stimulation started with HMG or purified

FSH when all ovarian follicles and the endometrial lining has disappeared on ultrasound (average: 15 days)

• one ongoing pregnancy achieved

Porter et al., 1984

The long luteal protocol

22nd dayof previous

cycle

14 days

1st dayof gonado-

tropins

gonadotropin administrationin an individualized dosage

ovulationinduction

oocytepick up

embryotransfer

luteal phase support

start ofGnRH agonist

GnRHa 剂量组

曲普瑞林 (mcg)

5 15 50 100

病例数 11 10 11 12

刺激天数 9 7.5 10 10.5

FSH使用量 24 22.5 27 28.5

S7-LH 3.3 1.5 1.3 0.8

HCG-LH 2.5 2.3 1.8 0.9

排卵 3 0 0 0

Source: Janssens et al, 1998

Regimen@

Lupron

Decapeptyl® 0.1 Alternate-day

Decapeptyl® 0.1

7-day

Total Cycle initiated Mean Age (range)

20

37.6 (32-44)

15

35.4 (32-42)

20

38.8 (36-44)

Serum LH (IU/L)

Day 3 Day 7

Day of hCG

4.4 2.4 2.7

2.2 1.6 1.5 (P<0.05)

2.7 1.9 2.4

Serum E2 (pmol/L)

Day 3 Day of hCG

48.5 2473

35.0 1429

45.9 1760

Regimen@

Lupron

Decapeptyl® 0.1 Alternate-day

Decapeptyl® 0.1

7-day

Total Cycle initiated Mean Age (range)

20

37.6 (32-44)

15

35.4 (32-42)

20

38.8 (36-44)

Means

# of eggs % fertilized

# clinical pregnancy pregnancy rate %

10 74 5

25.0

6.5 77 2

13.4

9.6 86 6

30.0

DECAPEPTYL DOWN REGULATION 2000-2003

< 40 ≥ 40

# of patients 90 76 (32.9) 14 (40.8)

# of pregnancy 42 40 2

Pregnancy % 46.7 52.6 14

# of twins+ 10 10 0

# of babies 43 42 1

Miscarriage rate 16% 50%

DECAPEPTYL DOWN REGULATION 2000-2003LABORATORY DATA

# of eggs 831 MTII 539 (67%)

MTI 139 (16.7%)

# of eggs ICSI 551

# of fertilized 427 Fert. % 76.4

# of E.T. 244 Mean transferred 2.7

# of preg. (F.H.) 46 Implantation rate 20.5%

GnRH agonists

Over-suppression:• LH becomes so low that it affects the

production of estrogen, and possibly progesterone in the luteal phase

• Leads to poor response, poor pregnancy outcome due to early abortion

Also it is:• Too long and too much drug use, cost,

cancelled cycles and it is unnatural.

Ovulation Stimulation Scheme

• BCP to control cycle (or ovulation monitor)

• BCP D16/ovulation +7day DECAPEPTYL

• Decapepyl 100mcg/day x 7 days

• D2 FSH, LH, E

• D3 Bravelle 225-300IU/day with monitor

• Choragon 10000IU for induction

• Endometrin BD (+ Progesterone)

BRAVELLE HKIVF DATA

# of OPU 19 11 <40, 8 ≥40

Total dose 887 (46) Range 26 – 68

# of eggs retrieved 193 MTII 126 (65%)

MTI 38 (20%)

Fertilization rate % 59%

Total # of Embryos Transfer 54 Average # of ET 2.8/opu

# of pregnancy 9

Pregnancy rate %/opu 47%

Implantation rate 37%

OVULATION STIMULATION

Comparison of protocols:

1. Decapeptyl Down Regulation

2. Long Lucrin Down Regulation

3. Antagonist, no down regulation

to achieve antagonistic properties of natural GnRH moremodifications than only in position 6 and 10 are necessary

1 2 43 65 98 107

pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2

activation of the GnRH receptor

regulation of GnRHreceptoraffinity

regulation ofbiologic activity

Structure of GnRH antagonists

Action of GnRH antagonists

LH + FSH

post-receptor-cascade

GnRH - receptor

GnRH

GnRH - antagonistpituitary suppression

Comparison of the long protocol and the antagonist protocols

agonist administrationagonist administration

gonadotropin administrationgonadotropin administration

long protocol

antagonist administrationantagonist administration

gonadotropin administrationgonadotropin administration

multiple dose protocol

flare upeffect

pituitarysuppression

no cystformation

no hormonalwithdrawal

longertreatment

less gona-dotropins

earlypregnancy?

morephysiologic

pre-treatment cycle treatment cycle

The Cetrotide® 0.25 mg multiple dose protocol

1st dayof gonado-

tropins

gonadotropin administrationin an individualized dosage

ovulationinduction

oocytepick up

embryotransfer

luteal phase support

1st dayof menstruation

Cetrotide® 0.25 mg administrationdaily s.c. starting on day 6 of stimulation

Possibilities to individualize the multiple dose protocol

• To avoid a premature LH rise the administration of cetrotide® 0.25 mg on day 6 of stimulation should be the standard procedure

• Using the standard procedure, a mean of 6.3 injections are necessary

• This is in accordance with the package size of 7 ampoules cetrotide® 0.25 mg per patient

Possibilities to individualize the multiple dose protocol

• Individualized administration of Cetrotide® 0.25 mg can be done– According to follicle size:

only if leading follicle is 14 mm

• Thereby, the multiple dose protocol can also be adapted to patients with a lower response

Personal experience with multiple dose of Cetrorelix 0.25 mg

Patient group:

• Over suppression with agonist long protocol (LH < 1mlU)

• Patient over 40

• Poor response to agonists suppression

Cetrorelix 0.125mg Flexible Dose Trial

Selection Criteria:

1. Previous over-suppression with agonist

2. Previous poor response

3. Previous LH surge if no agonist

Cetrorelix 0.125mg Flexible Dose Trial

Methods:

1. FSH LH E2 on day 2

2. U/S on day 3, start Gonal-F 225IU/day

3. Stimulation day 4, check E2 LH U/S

Cetrorelix 0.125mg Flexible Dose Trial

Treatment Criteria

1. LH > 1.5IU/L

2. Leading follicle = 15mm diameter

• Cetrorelix 0.125mg/day given until day of HCG injection

• Monitor by E2 LH U/S everyday

Age Distribution

0

1

2

3

4

5

6

7

<32 33-36 37-40 >40

Mean = 36.6 (range 29-44)

Cetrorelix 0.125mg Flexible Dose Trial

RESULTS

BMI Distribution

01

23

45

67

89

10

<20 20 21 22 >25

Mean = 21.8 (range 19-30)

Cetrorelix Start Cycle Day

0

1

2

3

4

5

6

7

8

5 7 9 11 13 15 17 19 21 23 25

FSH 225 IU/day SC starts on day 3

# Days Cetrorelix Used

01234567

89

10

1 2 3 4

Mean = 2.2 days (range 1-3)

LH and Cetrorelix 0.125mg/day

1.20.9

1.82.4

2.12.5

4.9

6

7.8

0

1

2

3

4

5

6

7

8

pre day 1post

dayHCG

Range mIU/ml• Pre 1.2 - 7.8• Day 1 post 0.9 - 4.9• Day HCG 1.8 - 6

Clinical Data

•Age•BMI

36.6 (29-44)

21.8 (19-30)

15<40yr 5>40yr

•Ova # per OPU•%MT II•% Fertilization

9 (1-16)

77%

74.4%

•Transfer # embryos•Pregnancy rate•Implantation rate

2.6 <40yr 4.8 >40yr

60%<40yr 40% >40yr

25.4% (16/63)

Experience with Cetrotide 0.125mg

No of cycles 75 Age 37.4 32 - 41

# eggs retrieved 9.6 4 - 23

% fertilised 83% # embryo trans 2.6 2 - 5

Pregnancies 36 (48%) Implant 23%

LH escape 1/75 1.3%

Ovulation Stimulation

<40

(41)

≥40

(6)

<40

(60)

≥40

(2)

<40

(117)

≥40

(58)

Average age 33.9 41 33.4 40.5 35.2 41.9

# of OPU 41 6 60 2 117 78

# of egg retreived

458 34 718 21 1272 443

# of MTII 307, 67% 22, 65% 510, 71% 12, 57% 881, 69% 313, 71%

# of MTI 81, 19% 8, 24% 126, 18% 4, 19% 202, 15% 60, 14%

Deca Long Luc Cet

Ovulation Stimulation

<40 ≥40 <40 ≥40 <40 ≥40

# of ICSI’d 364 29 586 19 1034 349

# of 2PN 280 20 435 15 756 263

Fertilization rate % 77% 69% 74% 79% 73% 75%

# of Embryos Tr 137 17 201 7 337 154

Mean # of ET 3.3 2.8 3.35 3.5 2.9 2.7

# of pregnancy 22 1 30 0 47 7

Pregnancy rate% opu 54% 17% 50% 0% 40% 12%

Implantation rate 19% 6% 22% 0% 15% 6%

Deca Long Luc Cet

Flexible Stimulation

• When dn reg showed over suppression

• Low E, LH, small follicles

• D2 E=30.7pg LH=0.54IU/L

• D6 E=214pg LH=0.7 IU/L

• rLH added to Bravelle dosage

• D(HCG) E=1856.5pg LH 1.45IU/L

• 6/8 cases pregnant

Infertility

• 1/6 couples trying for pregnancy

• Medical,social and psychological problems studied

• Very few perception studies

Perception study in Infertility

• Bertarelli Foundation Survey 2000• 1st published population perception survey• Polled 6 European Countries, USA and Australia

1998/1999• Telephone survey: random selection households• 7036 polled, no mention of % completion

Perception Survey in Infertility

• 6 questions

• Asked You/your friend to avoid rejection

• 52 % claimed personally know somebody who had infertility

Perception Study in Infertility

• Is Infertility a disease? Mean 38%• Australia, UK, USA 20%• Germany, Italy 55%

• Heard of IVF?• 77% (Germany) to 99% (Sweden)

Perception study in infertility

• Should IVF be reimbursed?

• Told respondent cost 3x IVF equals hip replacement

• 60-80% said to reimburse

Perception Study in Infertility

• Although 97% of respondents heard of IVF and approved of IVF, only 16% answered correctly that IVF success is similar to that of natural pregnancy.

• Most people guessed the success rate, and no correlation can be established

YWCA Perception Study 2002

• Aims:

• Infertility problem vs no problem

• psycho-social states

• medical aspects - treatment profiles

Bertarelli vs. Hong Kong Survey

Bertarelli

• 52% know infertility• 16% know success rate• 89% know IVF• 38% said infertility =

disease

Hong Kong

• 50% know infertility • 20%know success

rate• 46% know IVF• 50% said

infertility=disease

YWCA Perception Study 2002

• Methodology:

• Telephone survey

• Randomly called numbers

• No demographic questions to maximise response

• Respondents answer 7,15, or16 questions

YWCA Perception Study 2002

• Randomly dialed Numbers

• Carried out July to October

• Successfully Connected:147897

• Valid Data: 7028

• Success Rate: 5%

YWCA Perception Study 2002

0 20 40 60 80 100

infertile

no problem

Why Reject IVF

anti-religiousbelief

IVF=abnormalbabies

Ashame of beingknown to needivf

Too expensive45.7%

24%22.5%

7.8%

Investigations on Treated Subjects

Check - Hormone

Check - Hormone

NoYesP

erc

en

t

70

60

50

40

30

20

10

0

Check - USound

Check - USound

NoYes

Per

cent

60

50

40

30

20

10

0

Investigations done Treated subjects

Check - Semen

Check - Semen

NoYes

Pe

rce

nt

60

50

40

30

20

10

0

Check - FTube

Check - FTube

NoYes

Per

cent

60

50

40

30

20

10

0

Basic Investigations Made

0

20

40

60

80

100

SA HSG

HKG

USA

Summary of Results

• 16% of polled has infertility problem• 45% view infertility as disease. For infertile

couples 52% consider it a disease• 35% only has heard of IVF centers• 50% know the reason for their infertility• 30% know IVF success rate (20-40%)

Summary of Results

• 1173/7208 polled claimed to be infertile• only 265 (34%) have received or under

treatment• 50.6% had ovulation induction• 34% had intra-uterine insemination• 24% had IVF/related treatment

Summary of Results

• Diagnosis procedures reported• Ovulation/hormone, laparoscopy 35%• SA, HSG only 45%• Ultrasound only test >50% (58%)• 42% answered that none of the above tests

were done

Summary of Results

• Although 50% of respondents who are under treatment accepts IVF

• Only 30% actually received IVF treatment• This is 6.5% of respondents who has infertility• Of those rejecting IVF, 45.7% worry IVF begets

abnormal babies. 22.5% think too expensive

CONCLUSIONS

• There is misconception about IVF mainly in the availability, success rate, and the technology itself

• There is a problem of education, so that appropriate tests were not done

• Funding is not enough, especially third party payment

CONCLUSIONS

• Patients are not seeking treat-ment. Social factors and other psychological reasons may be present.

• May also be that right treatment is not readily offered, so treat-ment abandoned after a while

Cost Hip Replacement Vs IVF

• Hip Replacement• OT charge:$40000• Hospital Bed: $20000• Surgical Fee:$30000• Drugs etc: $5000• Total: $95000

• IVF• OT charge: $12000• Hospital bed:$3000• Surgical Fee:$15000• Lab Fee:$ 15000• Drugs etc:$15000• Total: $$60000

ACTION, STRUCTURE AND USE OF GnRH AGONISTS AND ANTAGONIST

Structure of GnRH antagonists

name amino acid sequenceGnRH pGlu – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2

1st generation4F Ant NAc1,1Pro – D4FPhe – DTrp – Ser – Tyr – DTrp – Leu – Arg – Pro – GlyNH2

2nd generationNalArg NACD2Nal – D4lFPhe=pTrp – Ser – Tyr – DArg – Leu – Arg – Pro – GlyNH2

Detirelix NACD2Nal – D4ClPhe – pTrp – Ser – Tyr – DHarg(Et2) – Leu – Arg – Pro – DAlaNH2

3rd generationNalGlu NACD2Nal – D4C7Phe – D3Pal – Ser – Arg – DGlut(AA) – Leu – Arg – Pro – DAlaNH2

Antide NACD2Nal – D4ClPhe – D3Pal – Ser – Lys(Nic) – DDLys(Nic) – Leu – Lys(Isp)Pro – DAlaNH2

Org30850 NACD4ClPhe – D4ClPhe – DBal – Ser – Tyr – DLys – Leu – Arg – Pro – DAlaNH2

Ramorelix NACD2Nal – D4ClPhe – DTrp – Ser – Tyr – DSet(Rha) – Leu – Arg – Pro – AzaglyNH2

Cetrorelix NACD2Nal – D4ClPhe – D3Pal – Ser – Tyr – DCit – Leu – Arg – Pro – DAlaNH2

Ganirelix NACD2Nal – D4ClPhe – D3Pal – Ser – Tyr – DHarg(Et2) – Leu – Harg(Et2) – Pro – DAlaNH2

A-75998 NACD2Nal – D4ClPhe – D3Pal – Ser – NMeTyr – DLys(Nic) – Leu – Lys(Isp) – Pro – DAlaNH2

Azaline B NACD2Nal – D4ClPhe – D3Pal – Ser – Aph(atz) – DAph(atz) – Leu – Lys(Isp) – Pro – DAlaNH2

Antarelix NACD2Nal – D4ClPhe – D3Pal – Ser – Tyr – DHcit – Leu – Lys(Isp) – Pro – DAlaNH2

Comparison: Mode of Actions

Antagonists Agonists

•Immediate onset of actions (shortens treatment durations)

•Prevents hormonal

withdrawal symptoms

•No recovery time of the pituitary

•long pre-treatment

•Hormonal (estrogen) withdrawal symptoms through desensitization of pituitary

•Recovery of the pituitary gonadotrophin secretion, after stopping the treatment takes about 2 weeks.

Characteristics of GnRH

Ganirelix

• Fully effective within 4 hours, with a half-life of about 13 hours

Cetrorelix

• Fully effective within 8 hours, with a half-life of about 36 hours

R.E. Felberbaum and K. Diedrich, 1999.

Ditkoff et al., 1991

Estradiol [pg/ml]

050

100150200250300350

-5 -4 -3 -2 -1 0 1

LH [mU/ml]

0

20

40

60

80

100

-5 -4 -3 -2 -1 0 1

Follicular diameters [mm]

14

16

18

20

22

-5 -4 -3 -2 -1 0 1

FSH [mU/ml]

0

5

10

15

20

25

30

-5 -4 -3 -2 -1 0 1

Days relative to ovulationcontrolNal-Glu cycles

Antagonists in controlled ovarian stimulation - the first steps

Reduction of OHSS using Cetrotide®

• Multiple dose protocol– rate of OHSS: 6.5% vs. 1.1% (agonist vs. antagonist protocol)– RR 6.2, 95% CI: 1.4 - 27.1, p = 0.03

• Single dose protocol– rate of OHSS: 11.1% vs. 3.5% (agonist vs. antagonist protocol)

95% CI: - 18.4 to 3.2– patients requiring hospitalisation: 5.6% vs. 1.8% (agonist vs. antagonist protocol)

95% CI: - 11.7 to 4.1

• With both Cetrotide® protocols a clear reduction of OHSS was achieved

Mean number of Cetrotide® 0.25 mg ampoules in the multiple dose protocol

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

number of injections

patie

nts (

%) average: 6.3 injections

The GnRH Antagonists

Conclusions:1. Why treat 100% of patients when we

are trying to prevent 5-10% LH surge2. Avoid over-suppression and poor

response3. Effective in preventing LH surge4. Reduction of hyper-stimulation5. Lower costs

Safety Profile

• Possible side effectsheadache, weakness, mild vaginitis & breast sensitivity etc

• No known drug interaction

• Overdoseunlikely & no side effects

Precautions

• History of depression, DM

• Not taken with other intravaginal products

• Not recommended during lactation

• Stored in a dry place, <25oC

Progesterone

Functions• Increase endometrial receptivity• Maintain pregnancy

Routes of administration• Injection (IM / IV)• Oral• Rectal• Vaginal, etc

Making BRAVELLE (GMP standards)

Pooled Post menopausal

urine

Crude filtration & clearance

Screening of eligible health

donors

Documentation on eligible donors

Aseptic Urine collection

#Ion exchange chromotographic

purification

Highly purified material

Pharmaceutical Lyophilization &

finishing

filtrate BRAVELLE

# Patent technology for FSH purification

Making rDNA FSH (Gonal-F, Puregon)

rFSH secreted by CHO cell into culture media

Crude filtration & clearance

Genetically Eng. CHO cells

Culturing CHO cells in media with Fetal

Bovine Serum (FBS)

Cultivating CHO cells in industrial size culturing tanks

Immuno chromotographic

purification

Highly purified material

Pharmaceutical Lyophilization &

finishing

filtrateGonal-F or Puregon collected & pooled

culture media