Choriogonadotropin Alfa (Monograph)

Brand name: Ovidrel
Drug class: Gonadotropins and Antigonadotropins
ATC class: G03GA08
VA class: HS900
Chemical name: Gonadotropin, chorionic (human α-subunit protein moiety reduced), complex with chorionic gonadotropin (human β-subunit protein moiety reduced)
Molecular formula: C₄₃₇H₆₈₂N₁₂₂O₁₃₄S₁₃
CAS number: 177073-44-8

Introduction

Gonad-stimulating hormone; biosynthetic (recombinant DNA-derived) form of human chorionic gonadotropin (hCG).¹

Uses for Choriogonadotropin Alfa

Female Infertility

Used in conjunction with other infertility agents (e.g., gonadotropin-releasing hormone agonist, FSH) for induction of final follicular maturation and early luteinization in ovulatory, infertile women during assisted reproductive technology (ART) programs.^{1 2 3 6 7 8 9}

Use in patients with tubal obstruction only if participating in ART programs.¹

Choriogonadotropin alfa (r-hCG) is equivalent to urinary-derived hCG with regard to number of oocytes recovered, fertilized oocytes or embryos, and live births.^{1 2 3}

Used in conjunction with follicle-stimulating agent to induce ovulation in anovulatory, infertile women in whom anovulation is functional and not due to primary ovarian failure.^{1 4 5 h}

Choriogonadotropin alfa (r-hCG) is similar to urinary-derived hCG with regard to ovulation rates.^{1 h}

Choriogonadotropin Alfa Dosage and Administration

General

• Should be prescribed only by clinicians experienced in infertility treatment and who are familiar with cautions, precautions, and contraindications associated with such therapy.^{1 4 5}

• Prior to treatment initiation with choriogonadotropin alfa, perform a thorough gynecologic and endocrinologic evaluation; assess pelvic anatomy and rule out early pregnancy, primary ovarian failure (as indicated by increased serum concentrations of FSH and LH and low serum estrogen concentrations), and neoplasms.^{1 4 5 6 7 c} (See Contraindications under Cautions.) Perform a thorough diagnostic evaluation in patients who demonstrate abnormal uterine bleeding and other signs of endometrial abnormalities.^{1 4} (See Contraindications under Cautions.) Evaluate partner’s infertility.^{1 4 5 6 h}

• When ultrasound assessment and serum estradiol concentrations show sufficient follicular maturation, administer choriogonadotropin alfa 1 day after last dose of follicle-stimulating agent to complete final follicular maturation and induce ovulation.^{1 4 5}

• Withhold further follicle-stimulating therapy and delay or withhold choriogonadotropin alfa if ovaries show an excessive response to treatment with gonadotropins because of increased risk of ovarian hyperstimulation syndrome (OHSS).^{1 4 5 6 i j} (See Ovarian Hyperstimulation Syndrome under Cautions.)

• Encourage daily sexual intercourse beginning 1 day prior to administration of choriogonadotropin alfa until ovulation occurs (as determined by rise in basal body temperature, increase in serum progesterone concentrations, and menstruation following shift in basal body temperature).^l (See Adequate Patient Evaluation and Monitoring under Cautions.)

• Examine ovaries by ultrasound for persistent cysts, particularly when attempts at stimulation of ovulation follow immediately after unsuccessful stimulated cycle.^{6 9}

Administration

Sub-Q Administration

Administer by sub-Q injection, generally into abdomen using commercially available prefilled syringe;¹ may be self-administered by patient.^{1 c}

Dosage

Adults

Female Infertility

ART

Sub-Q

250 mcg, given 1 day following last dose of follicle-stimulating agent.^{1 2 3} (See General under Dosage and Administration.)

Ovulation Induction

Sub-Q

250 mcg, given 1 day following last dose of follicle-stimulating agent.^{1 h} (See General under Dosage and Administration.)

If stimulation of ovulation is unsuccessful, adjust dosage of follicle-stimulating agent administered in subsequent cycles based on woman’s response in preceding cycle.^{6 9}

Prescribing Limits

Adults

Female Infertility

Sub-Q

Maximum 500-mcg single dose studied in clinical trials.^f

Related/similar drugs

testosterone, progesterone, clomiphene, Clomid, AndroGel, Xyosted, Pregnyl

Cautions for Choriogonadotropin Alfa

Contraindications

• Known hypersensitivity to human chorionic gonadotropin preparations (including urinary-derived hCG) or any ingredient in formulation.^{1 c}

• Primary ovarian failure.^{1 c}

• Uncontrolled thyroid or adrenal dysfunction.^{1 c}

• Uncontrolled organic intracranial lesions (e.g., pituitary neoplasms).^{1 c}

• Abnormal intrauterine or vaginal bleeding of undetermined origin.^{1 c}

• Ovarian cysts or enlargement of undetermined origin.^{1 c}

• Sex-hormone-dependent neoplasms of reproductive tract and accessory organs.^{1 c}

• Pregnancy.^{1 c}

Warnings/Precautions

Warnings

Ovarian Enlargement

Risk of mild to moderate uncomplicated ovarian enlargement; may be accompanied by abdominal distention and/or pain, but generally regresses without treatment within 2–3 weeks.¹ Careful monitoring of ovarian response recommended.¹

If ovaries are abnormally enlarged during controlled ovarian stimulation, withhold choriogonadotropin alfa during current course of therapy to minimize risk of OHSS.^{1 4 5 6 j} (See Ovarian Hyperstimulation Syndrome under Cautions.)

Ovarian Hyperstimulation Syndrome

Risk of potentially severe OHSS, characterized by apparent dramatic increase in vascular permeability that may result in rapid accumulation of fluid in peritoneal cavity, thorax, and potentially, pericardium.^{1 i j}

May progress rapidly (within 24 hours to several days).¹ Initial manifestations include severe pelvic pain, nausea, vomiting, and weight gain.^{1 i} Other symptoms include abdominal pain/distention, diarrhea, severe ovarian enlargement, dyspnea, and oliguria.^{1 j} Hypovolemia, hemoconcentration, electrolyte imbalances, ascites, hemoperitoneum, pleural effusions, hydrothorax, acute pulmonary distress, and thromboembolic events may occur.^{1 i j}

Transient liver function test abnormalities, which may be accompanied by morphologic changes (as detected by liver biopsy), reported.^{1 i j}

Occurs most often after completion of gonadotropin therapy, reaching maximum severity after 7–10 days; usually resolves spontaneously with onset of menses.^{1 i} Monitor patients for ≥2 weeks after hCG administration.^{1 l} OHSS may be more severe and protracted if pregnancy occurs.^{1 i}

If severe OHSS develops, discontinue therapy, hospitalize patient, and consult clinician experienced in management of OHSS or fluid and electrolyte imbalances.^{1 i}

Multiple Births

Multiple ovulations resulting in multiple gestations reported in 30.9 or 13.3% of women during ART programs or ovulation induction, respectively.¹

Risk of multiple births correlates with number of embryos transferred.^{1 6}

Thromboembolism

Potential for arterial thromboembolism exists.¹

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm; exclude pregnancy before initiating treatment.^d

Animal studies indicate adverse effects on pregnancy outcomes and/or labor.^d (See Contraindications under Cautions.)

General Precautions

Adequate Patient Evaluation and Monitoring

Administer only under supervision of qualified clinicians experienced in fertility disorders and interpretation of indices of ovulation.¹

Monitor follicular development (e.g., using transvaginal ultrasound, serum estradiol concentrations) to correctly identify follicular maturation, determine timing of choriogonadotropin alfa administration, detect ovarian enlargement, and minimize risks of OHSS and multiple gestation.^{1 4 5}

Obtain clinical confirmation of ovulation from direct and indirect indices of progesterone production, including rise in basal body temperature, an increase in serum progesterone concentrations, and menstruation following shift in basal body temperature.^{1 2 6 7} Sonographic evidence of ovulation includes findings of fluid in cul-de-sac, ovarian stigmata, collapsed follicle, and secretory endometrium.¹

Specific Populations

Pregnancy

Category X.¹ (See Fetal/Neonatal Morbidity and Mortality and also Contraindications under Cautions.)

Lactation

Not known whether choriogonadotropin alfa is distributed into milk.¹ Use caution.¹

Pediatric Use

Safety and efficacy not established.¹

Geriatric Use

Safety and efficacy not established.¹

Hepatic Impairment

Safety and efficacy not established.¹

Renal Impairment

Safety and efficacy not established.¹

Common Adverse Effects

ART: Injection site reactions (i.e., pain, bruising),^{1 2 3 f} abdominal pain,¹ nausea,¹ vomiting,¹ postoperative pain.¹

Ovulation induction: Injection site reactions (i.e., pain, inflammation, bruising, other injection site reaction),^{1 h} ovarian cysts,¹ ovarian hyperstimulation,^{1 h} abdominal pain.¹

Drug Interactions

No formal drug interaction studies to date.¹

Laboratory Tests

Choriogonadotropin Alfa Pharmacokinetics

Absorption

Bioavailability

Following sub-Q administration, absolute bioavailability is 40%.^{1 b} Peak serum concentrations attained in 12–24 hours; detectable in serum for 10 days.^{1 d e h}

Onset

Following midcycle administration, peak stimulation of luteal-phase progesterone production (as indicated by serum progesterone concentrations) occurs in approximately 5–7 days.^{e h} (See Actions.)

Duration

Following midcycle administration, stimulation of luteal-phase progesterone production persists for approximately 10 days.^{e h}

Distribution

Extent

Median apparent volume of distribution is 21.4 L in women undergoing in vitro fertilization.¹

Elimination

Metabolism

Urinary-derived hCG extensively metabolized, principally in the liver and kidneys, to active metabolites; urinary-derived choriogonadotropin alfa (r-hCG) exhibits similar pharmacokinetics as hCG.^{a k}

Elimination Route

Excreted in urine principally as metabolites.^a

Half-life

Biphasic; median terminal half-life is 29.2 hours in women undergoing in vitro fertilization.¹

Special Populations

Pharmacokinetics not evaluated in patients with renal or hepatic impairment.¹

Stability

Storage

Parenteral

Injection

2–8°C until dispensed.¹ Once dispensed, refrigerate prefilled syringe at 2–8°C, but may be stored at ≤25°C for ≤30 days; protect from light.^{1 c} Discard unused portion.¹

Actions

• A recombinant DNA-derived form of hCG prepared from genetically modified mammalian (Chinese hamster ovary) cells.^{1 2}

• An analog of LH; has physicochemical, immunologic, and biologic activities comparable to those of urinary-derived hCG.^{1 2}

• Substitutes for the endogenous LH surge responsible for ovulation and stimulates late maturation of the ovarian follicle, resumption of oocytic meiosis, and initiation of rupture of the preovulatory ovarian follicle.^{1 2 3 f} Spontaneous midcycle LH surges are inconsistent during controlled ovarian stimulation.^g

• Induces and maintains corpus luteum (as evidenced by increased serum progesterone concentrations).^{1 2 3 e f}

Advice to Patients

• Importance of informing patient of potential adverse effects (e.g., OHSS, multiple gestation).^{1 c}

• Importance of discussing duration of treatment and required monitoring procedures.¹

• Importance of patients informing clinician if severe pain or bloating in abdominal or pelvic area, severe upset stomach, vomiting, or weight gain occurs.^c

• Importance of patient informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.^c

• Importance of women informing their clinician if they plan to breast-feed.^c

• Importance of informing patient of other important precautionary information.¹ (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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