Pergoveris 300 Iu/150 Iu/450 Iu/225 Iu/900 Iu Solution

Pergoveris is indicated for the stimulation of follicular development in adult women with severe LH and FSH deficiency. In clinical trials, these patients were defined by an endogenous serum LH level < 1,2 IU/L.

Treatment with Pergoveris should be initiated under the supervision of a physician experienced in the treatment of fertility problems.

Posology

In LH and FSH deficient women (hypogonadotrophic hypogonadism), the objective of Pergoveris therapy is to develop a single mature Graafian follicle from which the oocyte will be liberated after the administration of human chorionic gonadotrophin (hCG). Pergoveris should be given as a course of daily injections. Since these patients are amenorrhoeic and have low endogenous oestrogen secretion, treatment can commence at any time.

Treatment should be tailored to the individual patientu2019s response as assessed by measuring follicle size by ultrasound and oestrogen response. A treatment regimen commences with the recommended dose of Pergoveris containing 150 IU r-hFSH/75 IU r-hLH daily. If less than the recommended dose daily is used, the follicular response may be unsatisfactory because the amount of lutropin alfa may be insufficient (see section 5.1).

If an FSH dose increase is deemed appropriate, dose adaptation should preferably be after 7-14 day intervals and preferably by 37,5-75 IU increments using a licensed follitropin alfa preparation. It may be acceptable to extend the duration of stimulation in any one cycle to up to 5 weeks. When an optimal response is obtained, a single injection of 250 micrograms of r-hCG or 5,000 IU to 10,000 IU hCG should be administered 24-48 hours after the last Pergoveris injection. The patient is recommended to have coitus on the day of, and on the day following, hCG administration. Alternatively, intrauterine insemination (IUI) may be performed. Luteal phase support may be considered since lack of substances with luteotrophic activity (LH/hCG) after ovulation may lead to premature failure of the corpus luteum. If an excessive response is obtained, treatment should be stopped and hCG withheld. Treatment should recommence in the next cycle at a dose of FSH lower than that of the previous cycle.

Special populations

Elderly
There is no relevant indication for the use of Pergoveris in the elderly population. Safety and effectiveness of this medicinal product in elderly patients have not been established.

Renal and hepatic impairment
Safety, efficacy, and pharmacokinetics of this medicinal product in patients with renal or hepatic impairment have not been established.

Paediatric population
There is no relevant use of this medicinal product in the paediatric population.

Method of administration

Pergoveris is intended for subcutaneous administration. The first injection should be performed under direct medical supervision. Self-administration should only be performed by patients who are well motivated, adequately trained and with access to expert advice. For instructions on the use of this medicinal product, see section 6.6.

Pergoveris is contraindicated in patients with:

• hypersensitivity to the active substances or to any of the excipients listed in section 6.1
• tumours of the hypothalamus and pituitary gland
• ovarian enlargement or ovarian cyst unrelated to polycystic ovarian disease and of unknown origin
• gynaecological haemorrhages of unknown origin
• ovarian, uterine or mammary carcinoma

Pergoveris must not be used when an effective response cannot be obtained, such as:

• primary ovarian failure
• malformations of sexual organs incompatible with pregnancy
• fibroid tumours of the uterus incompatible with pregnancy

Pergoveris contains potent gonadotrophic substances capable of causing mild to severe adverse reactions and should only be used by physicians who are thoroughly familiar with infertility problems and their management.

Gonadotrophin therapy requires a certain time commitment by physicians and supportive health care professionals, as well as the availability of appropriate monitoring facilities. In women, safe and effective use of Pergoveris calls for monitoring of ovarian response with ultrasound, alone or preferably in combination with measurement of serum oestradiol levels, on a regular basis. There may be a degree of interpatient variability in response to FSH/LH administration, with a poor response to FSH/LH in some patients. The lowest effective dose in relation to the treatment objective should be used in women.

Porphyria
Patients with porphyria or a family history of porphyria should be closely monitored during treatment with Pergoveris. In these patients, Pergoveris may increase the risk of an acute attack. Deterioration or a first appearance of this condition may require cessation of treatment.

Treatment in women
Before starting treatment, the couple's infertility should be assessed as appropriate and putative contraindications for pregnancy evaluated. In particular, patients should be evaluated for hypothyroidism, adrenocortical deficiency, hyperprolactinemia and appropriate specific treatment should be given.

Patients undergoing stimulation of follicular growth are at an increased risk of developing hyperstimulation in view of possible excessive oestrogen response and multiple follicular development.

Ovarian hyperstimulation syndrome (OHSS)
A certain degree of ovarian enlargement is an expected effect of controlled ovarian stimulation. It is more commonly seen in women with polycystic ovarian syndrome and usually regresses without treatment. In distinction to uncomplicated ovarian enlargement, OHSS is a condition that can manifest itself with increasing degrees of severity. It comprises marked ovarian enlargement, high serum sex steroids, and an increase in vascular permeability which can result in an accumulation of fluid in the peritoneal, pleural and, rarely, in the pericardial cavities.

The following symptomatology may be observed in severe cases of OHSS: abdominal pain, abdominal distension, severe ovarian enlargement, weight gain, dyspnoea, oliguria and gastrointestinal symptoms including nausea, vomiting and diarrhoea. Clinical evaluation may reveal hypovolaemia, haemoconcentration, electrolyte imbalances, ascites, haemoperitoneum, pleural effusions, hydrothorax, or acute pulmonary distress, and thromboembolic events. Very rarely, severe OHSS may be complicated by ovarian torsion or thromboembolic events such as pulmonary embolism, ischaemic stroke or myocardial infarction.

Independent risk factors for developing OHSS include young age, lean body mass, polycystic ovarian syndrome, higher doses of exogenous gonadotrophins, high absolute or rapidly rising serum oestradiol level (> 900 pg/mL or > 3,300 pmol/L in anovulation), previous episodes of OHSS and large number of developing ovarian follicles (3 follicles of u2265 14 mm in diameter in anovulation).

Adherence to recommended Pergoveris and FSH dosage and regimen of administration can minimise the risk of ovarian hyperstimulation.

Monitoring of stimulation cycles by ultrasound scans as well as oestradiol measurements are recommended to early identify risk factors. There is evidence to suggest that hCG plays a key role in triggering OHSS and that the syndrome may be more severe and more protracted if pregnancy occurs. Therefore, if signs of OHSS occur such as serum oestradiol level > 5,500 pg/mL or > 20,200 pmol/L and/or u2265 40 follicles in total, it is recommended that hCG be withheld and the patient be advised to refrain from coitus or to use barrier contraceptive methods for at least 4 days. OHSS may progress rapidly (within 24 hours) or over several days to become a serious medical event. It most often occurs after hormonal treatment has been discontinued and reaches its maximum at about seven to ten days following treatment. Usually, OHSS resolves spontaneously with the onset of menses. Therefore patients should be followed for at least two weeks after hCG administration. If severe OHSS occurs, gonadotropin treatment should be stopped if still ongoing. The patient should be hospitalised and specific therapy for OHSS started. This syndrome occurs with higher incidence in patients with polycystic ovarian disease. When a risk of OHSS is assumed, treatment discontinuation should be considered.

Ovarian torsion
Ovarian torsion has been reported after treatment with other gonadotropins. This may be associated with other risk factors such as OHSS, pregnancy, previous abdominal surgery, past history of ovarian torsion, previous or current ovarian cyst and polycystic ovarian syndrome. Damage to the ovary due to reduced blood supply can be limited by early diagnosis and immediate detorsion.

Multiple pregnancy
In patients undergoing induction of ovulation, the incidence of multiple pregnancies and births is increased compared with natural conception. The majority of multiple conceptions are twins. Multiple pregnancy, especially high order, carry an increased risk of adverse maternal and perinatal outcomes. To minimise the risk of multiple pregnancy, careful monitoring of ovarian response is recommended. The patients should be advised of the potential risk of multiple births before starting treatment. When risk of multiple pregnancies is assumed, treatment discontinuation should be considered.

Pregnancy loss
The incidence of pregnancy loss by miscarriage or abortion is higher in patients undergoing stimulation of follicular growth for ovulation induction than in the normal population.

Ectopic pregnancy
Women with a history of tubal disease are at risk of ectopic pregnancy, whether the pregnancy is obtained by spontaneous conception or with fertility treatments. The prevalence of ectopic pregnancy after assisted reproductive technologies (ART) was reported to be higher than in the general population.

Reproductive system neoplasms
There have been reports of ovarian and other reproductive system neoplasms, both benign and malignant, in women who have undergone multiple regimens for infertility treatment. It is not yet established whether or not treatment with gonadotropins increases the risk of these tumours in infertile women.

Congenital malformation
The prevalence of congenital malformations after ART may be slightly higher than after spontaneous conceptions. This is thought to be due to differences in parental characteristics (e.g. maternal age, sperm characteristics) and multiple pregnancies.

Thromboembolic events
In women with recent or ongoing thromboembolic disease or women with generally recognised risk factors for thromboembolic events, such as personal or family history, thrombophilia or severe obesity (body mass index > 30 kg/m2), treatment with gonadotrophins may further increase the risk. In these women, the benefits of gonadotrophin administration need to be weighed against the risks. It should be noted however, that pregnancy itself as well as OHSS also carries an increased risk of thromboembolic events.

Sodium
Pergoveris contains less than 1 mmol sodium (23 mg) per dose, i.e. essentially u201csodium-freeu201d.

Pergoveris solution for injection in pre-filled pen must not be administered as a mixture with other medicinal products in the same injection. Pergoveris solution for injection in pre-filled pen may be administered concomitantly with a licensed follitropin alfa preparation as separate injections.

Pregnancy
There is no indication for the use of Pergoveris during pregnancy. Data on a limited number of exposed pregnancies indicate no adverse reactions of follitropin alfa and lutropin alfa on pregnancy, embryonal or foetal development, parturition or postnatal development following controlled ovarian stimulation. No teratogenic effect of such gonadotropins has been reported in animal studies. In case of exposure during pregnancy, clinical data are not sufficient to exclude a teratogenic effect of Pergoveris.

Breastfeeding
Pergoveris is not indicated during breastfeeding.

Fertility
Pergoveris is indicated for use in infertility (see section 4.1).

Pergoveris has no or negligible influence on the ability to drive and use machines.

Summary of the safety profile
The most commonly reported adverse reactions are headache, ovarian cysts and local injection site reactions (e.g. pain, erythema, haematoma, swelling and/or irritation at the site of injection). Mild or moderate OHSS has been commonly reported and should be considered as an intrinsic risk of the stimulation procedure. Severe OHSS is uncommon (see section 4.4).

Thromboembolism may occur very rarely, usually associated with severe OHSS (see section 4.4).

Tabulated list of adverse reactions
Adverse reactions are listed below by MedDRA system organ class and by frequency. The frequency categories used are very common (u22651/10), common (u2265 1/100 to <1/10), uncommon (u22651 /1,000 to <1/100), rare (u2265 1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data).

Immune system disorders
Very rare: Mild to severe hypersensitivity reactions including anaphylactic reactions and Shock

Nervous system disorders
Very common: Headache

Vascular disorders
Very rare: Thromboembolism, usually associated with severe OHSS

Respiratory, thoracic and mediastinal disorders
Very rare: Exacerbation or aggravation of asthma

Gastrointestinal disorders
Common: Abdominal pain, abdominal distension, abdominal discomfort, nausea, vomiting, diarrhoea

Reproductive system and breast disorders
Very common: Ovarian cysts
Common: Breast pain, pelvic pain, mild or moderate OHSS (including associated symptomatology)
Uncommon: Severe OHSS (including associated symptomatology) (see section 4.4)
Rare: Complication of severe OHSS

General disorders and administration site conditions
Very common: Mild to severe injection site reactions (e.g. pain, erythema, haematoma, bruising, swelling and/or irritation at the site of injection)

Symptoms
The effects of an overdose of Pergoveris are unknown. Nevertheless, there is a possibility that OHSS may occur, which is further described in section 4.4.

Management
Treatment is directed to symptoms.