Repronex® (menotropins for injection) is a drug that should only be used by physicians who are thoroughly
familiar with infertility problems. It is a potent gonadotropic substance capable
of causing mild to severe adverse reactions in women. Gonadotropin therapy requires
a certain time commitment by physicians and supportive health professionals,
and its use requires the availability of appropriate monitoring facilities (see
PRECAUTIONS - Laboratory Tests). In female patients it must be used with
a great deal of care.
Overstimulation of the Ovary During Repronex® (menotropins for injection) Therapy
Ovarian Enlargement: Mild to moderate uncomplicated ovarian enlargement
which may be accompanied by abdominal distension and/or abdominal pain occurs
in approximately 5 to 10% of those treated with Repronex® menotropins and
hCG, and generally regresses without treatment within two or three weeks.
In order to minimize the hazard associated with the occasional abnormal ovarian enlargement which may occur with Repronex® (menotropins for injection) hCG therapy, the lowest dose consistent with expectation of good results, should be used. Careful monitoring of ovarian response can further minimize the risk of overstimulation.
If the ovaries are abnormally enlarged on the last day of Repronex® (menotropins for injection) therapy, hCG should not be administered in this course of therapy; this will reduce the chances of development of the Ovarian Hyperstimulation Syndrome.
The Ovarian Hyperstimulation Syndrome (OHSS): OHSS is a medical event distinct
from uncomplicated ovarian enlargement. OHSS may progress rapidly to become
a serious medical event. It is characterized by an apparent dramatic increase
in vascular permeability which can result in a rapid accumulation of fluid in
the peritoneal cavity, thorax, and potentially, the pericardium. The early warning
signs of development of OHSS are severe pelvic pain, nausea, vomiting, and weight
gain. The following symptomatology has been seen with cases of OHSS: abdominal
pain, abdominal distension, gastrointestinal symptoms including nausea, vomiting
and diarrhea, severe ovarian enlargement, weight gain, dyspnea, and oliguria.
Clinical evaluation may reveal hypovolemia, hemoconcentration, electrolyte imbalances,
ascites, hemoperitoneum, pleural effusions, hydrothorax, acute pulmonary distress,
and thromboembolic events (see "Pulmonary and Vascular Complications" below).
Transient liver function test abnormalities suggestive of hepatic dysfunction,
which may be accompanied by morphologic changes on liver biopsy, have been reported
in association with the Ovarian Hyperstimulation Syndrome (OHSS).
OHSS occured in 3 of 125 (2.4%) Repronex® (menotropins for injection) treated women during ART clinical
studies. None of these cases was classified as severe. In Ovulation Induction
clinical studies, 4 of 72 (5.5%) Repronex® (menotropins for injection) treated women developed OHSS
and of this number one case was classified as severe (1.4%). Cases of OHSS are
more common, more severe and more protracted if pregnancy occurs. OHSS develops
rapidly; therefore patients should be followed for at least two weeks after
hCG administration. Most often, OHSS occurs after 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. If there is evidence that
OHSS may be developing prior to hCG administration (see PRECAUTIONS - Laboratory
Tests), the hCG should be withheld.
If OHSS occurs, treatment should be stopped and the patient hospitalized. Treatment is primarily symptomatic, consisting of bed rest, fluid and electrolyte management, and analgesics if needed. The phenomenon of hemoconcentration associated with fluid loss into the peritoneal cavity, pleural cavity, and the pericardial cavity has been seen to occur and should be thoroughly assessed in the following manner: 1) fluid intake and output, 2) weight, 3) hematocrit, 4) serum and urinary electrolytes, 5) urine specific gravity, 6) BUN and creatinine, and 7) abdominal girth. These determinations are to be performed daily or more often if the need arises.
With OHSS there is an increased risk of injury to the ovary. The ascitic, pleural, and pericardial fluid should not be removed unless absolutely necessary to relieve symptoms such as pulmonary distress or cardiac tamponade. Pelvic examination may cause rupture of an ovarian cyst, which may result in hemoperitoneum, and should therefore be avoided. If this does occur, and if bleeding becomes such that surgery is required, the surgical treatment should be designed to control bleeding and to retain as much ovarian tissue as possible. Intercourse should be prohibited in those patients in whom significant ovarian enlargement occurs after ovulation because of the danger of hemoperitoneum resulting from ruptured ovarian cysts.
The management of OHSS may be divided into three phases: the acute, the chronic, and the resolution phases. Because the use of diuretics can accentuate the diminished intravascular volume, diuretics should be avoided except in the late phase of resolution as described below.
Acute Phase: Management during the acute phase should be designed to
prevent hemoconcentration due to loss of intravascular volume to the third space
and to minimize the risk of thromboembolic phenomena and kidney damage. Treatment
is designed to normalize electrolytes while maintaining an acceptable but somewhat
reduced intravascular volume. Full correction of the intravascular volume deficit
may lead to an unacceptable increase in the amount of third space fluid accumulation.
Management includes administration of limited intravenous fluids, electrolytes,
and human serum albumin. Monitoring for the development of hyperkalemia is recommended.
Chronic Phase: After stabilizing the patient during the acute phase,
excessive fluid accumulation in the third space should be limited by instituting
severe potassium, sodium, and fluid restriction.
Resolution Phase: A fall in hematocrit and an increasing urinary output
without an increased intake are observed due to the return of third space fluid
to the intravascular compartment. Peripheral and/or pulmonary edema may result
if the kidneys are unable to excrete third space fluid as rapidly as it is mobilized.
Diuretics may be indicated during the resolution phase if necessary to combat
Pulmonary and Vascular Complications
Serious pulmonary conditions (e.g., atelectasis, acute respiratory distress syndrome) have been reported. In addition, thromboembolic events both in association with, and separate from, the Ovarian Hyperstimulation Syndrome have been reported following menotropins therapy. Intravascular thrombosis and embolism, which may originate in venous or arterial vessels, can result in reduced blood flow to critical organs or the extremities. Sequelae of such events have included venous thrombophlebitis, pulmonary embolism, pulmonary infarction, cerebral vascular occlusion (stroke), and arterial occlusion resulting in loss of limb. In rare cases, pulmonary complications and/or thromboembolic events have resulted in death.
Multiple pregnancies have occurred following treatment with Repronex® (menotropins for injection) IM and SC. In a clinical trial for ovulation induction in which Repronex® (menotropins for injection) IM and Repronex® (menotropins for injection) SC were directly compared, the rates of multiple pregnancies were as follows. Of the four clinical pregnancies with Repronex® (menotropins for injection) IM, two were single and two were multiple pregnancies. Both multiple pregnancies were triplet pregnancies. Of the six clinical pregnancies with Repronex® (menotropins for injection) SC, three were single and three were multiple pregnancies. The three multiple pregnancies included one twin pregnancy and two quadruplet pregnancies.
In a clinical trial of IVF patients in which Repronex® (menotropins for injection) IM and Repronex® (menotropins for injection) SC were directly compared, the rates of multiple pregnancies were as follows. Of the 24 continuing pregnancies on Repronex® (menotropins for injection) IM, 14 were single and 10 were multiple pregnancies. The ten multiple pregnancies included three triplet and seven twin pregnancies. Of the 29 continuing pregnancies on Repronex® (menotropins for injection) SC, 14 were single and 15 were multiple pregnancies. The 15 multiple pregnancies included three quadruplet, three triplet and nine twin pregnancies. The patient and her partner should be advised of the potential risk of multiple births before starting treatment.
Hypersensitivity/anaphylactic reactions associated with menotropins administration have been reported in some patients. These reactions presented as generalized urticaria, facial edema, angioneurotic edema, and/or dyspnea suggestive of laryngeal edema. The relationship of these symptoms to uncharacterized urinary proteins is uncertain.