"Serono Meeting for Assisted Reproductive Technology (SMART VI)", Cape Town, South Africa, April 2010

1. SMART VI – Cape Town, South Africa – April 2010

6. LH Surge Prevention: GnRH Agonists Esteves, pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH 2

7. LH Surge Prevention: Antagonists Esteves, pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH 2 GnRH receptor activation Receptor affinity Biologic activity

12. Esteves et al, Reprod Biol Endocrinol. 2009; 7:111 Parameter HMG n=299 HP-hMG N=330 r-hFSH n=236 p value No. days stimulation 9.6 10.0 10.1 <0.01 Gonadotropin dose (IU) % Step-down 2,685 18.7 2,903 20.3 2,268 53.4 <0.01 No. retrieved oocytes 10.9 10.7 10.8 NS No. MII oocytes 8.9 8.9 8.7 NS 2PN fertilization (%) 72 72 71 NS Top quality embryos (%) 40 47 39 0.004 Implantation rate (%) 24 27 23 NS Live birth rate per cycle (%) 24.4 32.4 30.1 NS OHSS (%) 2.3 1.8 1.3 NS

13. Esteves et al, Reprod Biol Endocrinol. 2009; 7:111

14. Cycle Programming in GnRH Antagonist Cycles hCG or GnRH-a bolus Stimulation day hCG or GnRH-a bolus Cetrorelix; Ganirelix 0 1 2 3 4 5 6 7 8 9 10 11 12 13 gonadotropin 0.25 mg multiple dose protocol (fixed or flexible) Stimulation day Cetrorelix 0 1 2 3 4 5 6 7 8 9 10 11 12 13 gonadotropin 3 mg single dose protocol 2 CD1 OC OC Scheduling 14-28 days 2-5 pill-free days 2-5 pill-free days

15. Comparison of Long GnRH Agonist and GnRH Antagonist Protocols Agonist administration Gonadotropin administration Long GnRH agonist protocol Antagonist administration Gonadotropin administration Single or multiple dose GnRH antagonist protocol Flare up effect Pituitary suppression Pre-treatment cycle Treatment cycle Less gona- dotropins? Prevent OHSS by GnRH-a

17. GnRH Antagonists Effects on Cycle Parameters and Clinical Study Results Esteves,

18. Impact of E 2 Change Following Antagonist Administration Olivennes, et al. Fertil Steril 1998;70:S14 Although some patients experience a decline or plateau in E 2 following antagonist administration, there is no evidence of negative impact on treatment outcome. Esteves, Days post Cetrorelix 3 mg 0 400 800 1200 1600 Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 0 5 10 15 20 Follicle Size (mm) Estradiol (pg/ml) Lead Follicle E 2

20. Antagonists and Endometrium Receptivity GnRH antagonists and endometrial receptivity in oocyte recipients: a prospective randomized trial Prapas N et al, RBM Online. 2009; 18:276. NS Pregnancy 55.1% 59.1% Implantation 26.1% 24.4

22. Antagonist Protocols Flexible or Fixed? Mansour, et al. Human Reprod 2002;17(Suppl 1):33 *Mean ± SD; NS = not significant Esteves, Cetrorelix 0.25mg Flexible (15 mm) N=64 Fixed (day 6) N=59 P value Age* 28.2 ± 3.7 27.3 ± 4.6 NS Oocytes retrieved* 12 ± 6.6 10.3 ± 4.7 NS Metaphase II oocytes* 9.6 ± 5.2 8.5 ± 4.2 NS Fertilization rate 79.2% 75.8% NS Pregnancy rate 51.6% 44.1% NS Implantation rate 27.3% 25.9% NS Number of cetrorelix vials used* 3.4 ± 1.1 5.3 ± 1.8 <0.05

26. Kolibianakis et al . Hum Reprod Update . 2006;12:651 Meta-Analyses of GnRH Antagonists vs GnRH Agonists Cumulative meta-analyses on live birth rates

27. Meta-Analyses of GnRH Antagonists vs GnRH Agonists *Live birth rate included ongoing pregnancies (Al-Inany) or calculated rates (Kolibianakis). 1. Al-Inany et al . Cochrane Database Syst Rev . 2006;3:CD001750. 2. Kolibianakis et al . Hum Reprod Update . 2006;12:651. Probability of Live birth *2.7% reduction in LBR (NS) Esteves, Al-Inany et al (2006) 1 Kolibianakis et al (2006) 2 N studies 27 22 Included non peer-reviewed data Yes No Included IUI cycles Yes No N patients 3865 3176 Primary outcome Ongoing PR or LBR LBR Odds ratio 0.82 (0.69-0.98; p=.03) 0.86 (0.72-1.02; p=.08)*

28. Griesinger et al. Reprod Biomed Online . 2006;13:628. Meta-Analyses of GnRH Antagonists vs GnRH Agonists Esteves, Poor Responders PCOS

29. Meta-Analyses of GnRH Antagonists vs GnRH Agonists *For every 59 women treated with a GnRH agonist vs GnRH antagonist, one additional case of severe OHSS will occur. 1. Al-Inany et al . Cochrane Database Syst Rev . 2006;3:CD001750. 2. Kolibianakis et al . Hum Reprod Update . 2006;12:651. Esteves, Al-Inany et al 1 Kolibianakis et al 2 Duration of ovarian stimulation -1.13 days (-1.83; -0.44) -1.54 days (-2.42; -0.66; p=.0006) Oocytes retrieved -- -1.19 (-1.82; -0.56) Risk of severe OHSS RR=0.46* (0.26; 0.82; p=.01) OR=0.61 (0.42; 0.89; p=.01)

30. The time is for the introduction of antagonists in clinical practice Esteves, Myths Facts E2 decrease is detrimental No evidence Need LH supplementation No evidence; works well irrespective of gonadotropin Not been able to program OCP Use of OC with similar results LH surge No evidence; last dose on hCG day Difficult to use There is a learning curve Adverse effect on endometrium No evidence Lower LBR Probability of LB is independent of analog used for pituitary suppression