Recombinant FSH versus urinary gonadotrophins (HMG, purified FSH, highly purified FSH) for ovarian hyperstimulation in IVF and ICSI cycles

van Wely M, Kwan I, Burt AL, Thomas J, Vail A, Van der Veen F, Al-Inany HG

Published Online:

April 13, 2011

Several systematic reviews compared recombinant FSH with urinary gonadotrophins (HMG, purified FSH, highly purified FSH) for ovarian hyperstimulation in IVF and ICSI cycles and these reported conflicting results. We included 42 trials with in total 9606 couples. Comparing rFSH with urinary gonadotrophins overall did not result in any difference in live birth rate, OHSS or any of the other outcomes. Comparing rFSH with HMG/HP-HMG resulted in a significantly lower live birth rate in the rFSH group though differences were small. There was no proof of a difference in live birth when comparing rFSH with FSH-P or with FSH-HP. We may conclude that all these gonadotrophins are equally effective and safe, and that further trials are unwarranted.

Abstract (click to read)

Background:

Several systematic reviews compared recombinant gonadotrophin with urinary gonadotrophins (HMG, purified FSH, highly purified FSH) for ovarian hyperstimulation in IVF and ICSI cycles and these reported conflicting results. Each of these reviews used different inclusion and exclusion criteria for trials. Our aim in producing this review is to bring together all randomised studies in this field under common inclusion criteria with consistent and valid statistical methods.

Objectives:

To compare the effectiveness of recombinant gonadotrophin (rFSH) with the three main types of urinary gonadotrophins (i.e. HMG, FSH-P and FSH-HP) for ovarian stimulation in women undergoing IVF or ICSI treatment cycles.

Search strategy:

An extended search was done according to Cochrane guidelines including the Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials (up to May 2010), The Cochrane Central Register of Controlled Trials (up to May 2010), MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), National Research Register, and Current Controlled Trials (up to May 2010).

Selection criteria:

All randomised controlled trials reporting data comparing clinical outcomes for women undergoing IVF/ICSI cycles and using recombinant FSH in comparison with HMG or highly purified HMG, purified urinary FSH (FSH-P), and highly purified urinary FSH (FSH-HP) for ovarian hyperstimulation in IVF or ICSI cycles were included.

Data collection and analysis:

Data selected by three reviewers (MvW, IK, and AV). Data extraction and risk assessment done by four reviewers (MvW, IK, AB and AV). Primary outcome measure was live birth rate and OHSS per randomised woman. Binary outcomes were analysed using odds ratios and also reported in absolute terms. Grouped analyses were carried out for all outcomes to explore whether relative effects differed due to key features of the trials.

Main results:

We included 42 trials with a total of 9606 couples. Comparing rFSH to any of the other gonadotrophins irrespective of the down-regulation protocol used, did not result in any evidence of a statistically significant difference in live birth rate (28 trials, 7339 couples, odds ratio 0.97, 95% CI 0.87 to 1.08). This suggests that for a group with a 25% live birth rate using urinary gonadotrophins the rate would be between 22.5% and 26.5% using rFSH. There was also no evidence of a difference in the OHSS rate (32 trials, 7740 couples, OR 1.18, 95% CI 0.86 to 1.61). This means that for a group with 2% risk of OHSS using urinary gonadotrophins, the risk would be between 1.7% and 3.2% using rFSH.

Authors' conclusions:

Clinical choice of gonadotrophin should depend on availability, convenience and costs. Further research on these comparisons is unlikely to identify substantive differences in effectiveness or safety.

This record should be cited as:

van Wely M, Kwan I, Burt AL, Thomas J, Vail A, Van der Veen F, Al-Inany HG. Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD005354. DOI: 10.1002/14651858.CD005354.pub2

Assessed as up to date:

October 20, 2010

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Subfertility > Female: assisted conception techniques

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Recombinant FSH versus urinary gonadotrophins (HMG, purified FSH, highly purified FSH) for ovarian hyperstimulation in IVF and ICSI cycles

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