10. • Pregnancies and live births are achieved more effectively and
faster after OI with low-dose FSH than with CC.
• This result has to be balanced by convenience and cost in
favour of CC.
• FSH may be an appropriate first-line treatment for some
women with PCOS and anovulatory infertility, particularly
older patients. Homburg et al, 2012
CC vs low-dose FSH for treatment of infertile
women with PCOS: a randomized multinational
study
13. 666 Women
• Gn group had more livebirths than CC
• [52%] vs [41%] p=0·012
• Addition of IUI did not increase
livebirths compared with intercourse
p=0·11
• But what about cost ??
14. The M-OVIN (Hum Reprod. 2019)
• Although Gn is more effective
• CC is more cost effective
• More twins with Gn
22. Assessed for eligibility (n= 245)
Excluded (n= 15)
Not meeting inclusion criteria (n=7)
Refused to participate (n=5)
Social reasons (n=3)
Received IUI (110)
Analyzed (n=110)
Cycles cancelled (n=5)
Inadequate response (n=4)
Hyper-response (n=1)
Group I (n=115) received Merional + CC
Cycles cancelled (n=8)
Inadequate response (n=6)
Hyper-response (n=2)
Group II (n=115) received Merional alone
Received IUI (107)
Analyzed (n=107)
Allocation
Analysis
Follow-Up
Enrollment
Randomized (n=230)
23. Both groups
• Folliculometry
• hCG when follicle reach 18mm or more
• Serum LH on day of hCG
• IUI 34-36hs later
• Micronised progesterone for 18 days
24. Results
Variable HMG/CC
(n=110)
HMG
(n=107)
P value
LH on day of hCG (miu/ml) for
cases with no premature LH surge
7.3 ± 1.8 7.8 ± 2.2 NS
Number of Follicles ≥ 16 mm 2.4 ± 0.97 1.3 ± 1.1 P < 0.05*
Number of patients with premature
LH surge
6 (5.45%) 17 (15.89%) P<0.001*
End. Thickness (mm) 5.9 ± 0.7 4.9 ± 1.9 NS
Clinical Pregnancy 11 (10%) 9 (8.41%) NS
29. 4G O.I strategy
• Initial use of Gn for 3 days
followed by CC seems to be
cost effective regimen
• Avoid CC resistance
• Maintain one follicle growing
40. IVF Transition Probabilities
• Probability of
discontinuation at
the end of the cycle
(failed clinical
pregnancy) for non-
medical reasons 1
Cycle Value
1 0.489
2 0.524
3 0.571
1 Schröder et al. Cumulative pregnancy rates and drop-out rates in a
German IVF programme: 4102 cycles in 2130 patients. May 2004
42. Rec FSH
rFSH : By the end of the 3rd cycle, the individual’s
probability of ending at re-starting the cycle is 2.2%,
in live birth rate is 34.6%, and in discontinuing IVF is
66.3 %
% Start Cycle
% Pregnancy
% Stop IVF
0
0.2
0.4
0.6
0.8
1
1.2
1 2 3 stop
Cycle
Probability
43. hMG
% Start Cycle
% Pregnancy
% Stop IVF
0
0.2
0.4
0.6
0.8
1
1.2
1 2 3 stop
Cycle
Probability
hMG: By the end of the 3rd cycle, the individual’s
probability of ending at re-starting the cycle is 6%, in
live birth is 45.2%, and in discontinuing IVF is 60.3 %
54. Convenience and Side Effects of
Route of P4 Administration
Intramuscular
pain
Local Reaction,
Severe Allergic Reaction (rare)
Vaginal
irritation, and soreness
65. Business Model : 6 Oct.
• El Wadi Hospital
• Division of Obstetrics & Gynecology
• 16 room
• 4 O.R
• X 50,000 Corporate
• Target 2 million
• Access to Hospital – IVF center
66. Thank you
Dr. Hesham Al-Inany MD, PhD
e-mail : kaainih@yahoo.com
Mobile : 01112220298