EA041804B1 - METHODS OF TREATMENT OF FEMALE INFERTILITY - Google Patents

Description

Cross-reference to related applications

This application claims priority over U.S. Provisional Application No. 62/402018, filed September 30, 2016; and U.S. Provisional Application No. 62/402150, filed September 30, 2016, which are incorporated herein by reference in their entirety.

Link to sequence listing

The sequence listing associated with this invention is presented in text format instead of a paper copy and is hereby incorporated by reference into the description of the invention. The name of the text file containing the sequence listing is MYOV_017_01WOSeqList_ST25_txt. The text file is approx. 4 kb, was created on September 13, 2017 and was submitted electronically via EFS-Web.

Technical field

This invention relates to the field of assisted reproductive technology (ART), and more specifically to methods and uses for performing ART in women at risk of OHSS (ovarian hyperstimulation syndrome) and to methods and uses for promoting egg maturation, supporting the luteal phase, and inhibiting premature ovulation.

Prior Art

Approximately 1.5 million assisted reproductive technology procedures are performed worldwide every year. In addition, approximately 25% of women suffering from infertility have problems achieving ovulation, including an inability to produce fully mature eggs (also called oocytes) or an inability to ovulate. Fertility specialists help reproduction by using a group of medications to temporarily correct ovulation problems and increase a woman's chances of getting pregnant. Many assisted reproductive technology cycles include one or more of the following stages as part of the ultimate goal of pregnancy: (1) the maturation of ovarian follicles, which control the release of eggs in the ovaries; (2) prevention of premature ovulation; (3) initiating egg maturation at the right time; (4) egg retrieval and fertilization; and (5) transplantation of a fertilized egg followed by biochemical pregnancy tests. However, other important ART regimens include oocyte conservation or donation; regulation of the menstrual cycle, which creates the possibility of passing ovulation after initiation (3), followed by intrauterine insemination (IUI) or sexual intercourse at a given time. Also for women with primary ovarian dysfunction (eg, women unable to bring an oocyte to maturity or ovulation even with ART) or as part of a surrogate pregnancy procedure, an embryo transfer (ET) with luteal phase support may be used, with a luteal phase support agent may be administered before, simultaneously with, or after PE, or administered at one or more prior time points.

Traditional ART protocols have used agents such as follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG) in the initial stimulation phase, preceded by administration of a gonadotropin-releasing hormone (GnRH) agonist (GnRH receptor agonist) or the addition of a GnRH antagonist (GnRH receptor antagonist) to prevent (suppress) ovulation and prevent the release of immature oocytes due to the release of luteinizing hormone (LH). Ovulation is suppressed so that eggs can mature and be later retrieved directly from the ovaries (rather than from the fallopian tubes), and to prevent high-grade multiple pregnancies that can result from exposure of eggs to sperm in the fallopian tube if they come into contact. Together, this stimulation process with FSH and a GnRH antagonist or agonist is called controlled ovarian stimulation (COS). Once the follicles have progressed to a predetermined state in which a number of oocytes are ready for final maturation, an oocyte maturation agent, or so-called trigger agent (e.g., human chorionic gonadotropin (hCG or hCG), a GnRH agonist, or both), is used, with the purpose of (1) promoting the final maturation and release of eggs from the ovary in preparation for intercourse or IUI, or (2) for the final maturation and retrieval of oocytes followed by PE in the uterus, for ART regimens that include an implantation stage (for example, in vitro fertilization ( IVF, IVF)). The induction of terminal oocyte maturation is a procedure that is usually performed as part of the COS to ensure that the oocytes are fully developed, resulting in a good yield of oocytes for retrieval, and optimal chances of pregnancy. Thus, the trigger essentially replaces the LH surge, the effects of which include the final maturation of oocytes before ovulation in natural menstrual cycles. In IVF cycles, initiating final oocyte maturation with a GnRH agonist instead of hCG reduces the risk of ovarian hyperstimulation syndrome (OHSS) but also reduces the rate of live birth. In ART cycles followed by oocyte donation, the use of GnRH agonists instead of hCG reduces the risk of OHSS in the absence of data indicating a reduction in the rate of live births. GnRH agonist- and hCG-initiated IVF cycles have similar rates of oocyte yield and embryo quality.

After administration of the triggering agent, other agents (eg, hCG and estradiol and progestins) are used to support the uterus (endometrium), the so-called luteal phase support, in preparation for implantation. Support of the luteal phase is necessary because after COS gonadotropins are observed disorders caused by inhibition of LH secretion by supraphysiological concentrations of steroid hormone through negative feedback at the level of the hypothalamic-pituitary-gonadal axis. Due to low LH levels, without luteal phase support, progesterone levels will drop, resulting in a lower chance of successful implantation and therefore pregnancy.

Human chorionic gonadotropin (hCG) is used as a trigger due to its structural similarity to LH and its ability to activate LH receptors and act as a trigger agent, resulting in significant numbers of mature oocytes. With hCG's long half-life (24-36 hours) and ability to activate LH receptors for seven to ten days, and sometimes even up to 16 days, hCG also provides luteal phase support by increasing progesterone. Thus, hCG can be used as a trigger (oocyte maturation) and/or to support the luteal phase. In addition, the use of hCG therapies as trigger agents is known to result in the production of significant numbers of mature oocytes. However, the use of hCG for any of these purposes is associated with a very high risk of OHSS. This raises safety concerns for women at high risk of OHSS and may lead to a greater need for segmented freezing protocols (i.e. embryo cryopreservation followed by transfer of a frozen and thawed embryo in a subsequent menstrual cycle), which may reduce OHSS but will delay PE and timing of pregnancy. As described in more detail below, in OHSS, the ovaries may enlarge, fluid may accumulate in the abdomen (ascites), and the patient may experience bloating and pain, nausea, and diarrhea. Severe forms of OHSS can cause hemoconcentration, thrombosis, elevated white blood cell count, oliguria, renal failure, pleural effusion, respiratory failure including acute respiratory distress syndrome, and even death.

Ovarian hyperstimulation syndrome (OHSS) is a significant complication (side effect) of ART. Ovarian hyperstimulation syndrome (OHSS) is believed to result from supraphysiological LH receptor agonism in the ovary resulting from egg maturation initiated by human chorionic gonadotropin (acting directly on ovarian LH receptors) and, to a lesser extent, GnRH receptor agonists (initiating the release of endogenous LH exceeding that observed during a normal cycle) in ovaries with a large number of mature follicles. The central feature of clinically significant OHSS is the development of vascular hyperpermeability causing fluid shifts. The use of hCG causes extensive luteinization of the ovary, where large amounts of estrogens, progesterone, and local cytokines are released. Exogenous hCG may have long-term effects in vivo, which are probably caused by prolonged overactivation of LH receptors. The production of vascular endothelial growth factor (VEGF) by follicles under the influence of hCG may enhance the vascular hyperpermeability underlying OHSS. Severe OHSS has been described in up to 2% of the total IVF population, and in up to 20% of patients at high risk of developing OHSS, such as those with polycystic ovary syndrome (PCOS).

The use of a GnRH agonist as a trigger agent is associated with a lower incidence of OHSS, but also results in lower pregnancy rates, especially without exogenous luteal phase support. Protocols using GnRH agonist triggers require the administration of agents to support the luteal phase because the LH surge for such triggers is abrupt (eg, a peak with amplitude sufficient to initiate final maturation, but with a short wavelength) and short duration (< 20 hours or sometimes 24-36 hours). In addition, circulating levels of progesterone and estradiol after the GnRH agonist trigger are significantly lower during the luteal phase compared to those obtained after initiation with hCG due to the shorter half-life of LH (approx. 60 min) compared to hCG. Without exogenous luteal phase support after a GnRH agonist trigger, premature luteolysis and implantation failure are possible. In addition, the risk of OHSS is not completely eliminated with the use of a GnRH agonist as a triggering agent, and frozen embryo transfer in a subsequent menstrual cycle to reduce the risk of OHSS is still considered safer. In addition, there is a desire to reduce the time to pregnancy for women undergoing ART without increasing the risk of OHSS. Currently, it is difficult to provide a fresh transfer option while reducing the risk of OHSS and achieving the desired levels of luteal phase support, mature oocyte yield, pregnancy rate, and live birth rate.

Given the need to improve both safety and efficacy, it is desirable to provide new triggering agents for ART, as well as additional agents that can be administered to support the luteal phase.

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The essence of the invention

This invention relates to methods, uses and compositions for helping women with infertility problems. In other aspects, this invention relates to an increase in endogenous LH levels in a woman in need of such an increase. In some aspects, this invention relates to luteal phase support, which provides improved safety and efficacy of the ART process by providing an alternative to current methods of luteal phase support. A woman can undergo ART procedures or not. One potential benefit of such improved methods and applications is that they can significantly reduce the risk of OHSS for women undergoing ART procedures.

One aspect of the invention relates to a method for increasing endogenous LH levels in a woman in need thereof, comprising administering to the woman an initial dose of from about 0.00003 to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L- n-rolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide (herein referred to as compound 1), or an appropriate amount of a pharmaceutically acceptable salt thereof, and a woman is undergoing ART procedures and is at risk of OHSS, and after the initial dose, the woman's endogenous LH level in the blood is increased compared to the woman's endogenous LH level before the initial dose.

Another aspect of the invention relates to a method for increasing the level of endogenous LH in a woman undergoing ART procedures in need thereof, comprising administering to the woman an initial dose of from about 0.00003 mg to about 0.030 mg of Compound 1, or an appropriate amount of its pharmaceutically acceptable salt, and the woman undergoes the procedures ART, and for at least 36 hours after the initial dose, the level of endogenous LH in the woman's blood is increased compared to the level of endogenous LH in the woman's blood before the initial dose.

One aspect of the invention relates to a method for increasing the level of endogenous LH in a woman undergoing ART procedures in need thereof, comprising administering to the woman an initial dose of from about 0.00003 to about 0.030 mg of compound 1, or an appropriate amount of its pharmaceutically acceptable salt, and the woman undergoing ART procedures , and the maximum level of endogenous LH in the blood is observed at least about 12 hours after the introduction of the initial dose.

Another aspect of the invention relates to 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl- L-tryptophanamide, or a pharmaceutically acceptable salt, for use in a method of increasing endogenous LH levels in a woman undergoing ART procedures at risk of OHSS, the method comprising administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N- acetyl-D-tyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl-E-threonyl-E-phenylalanyl)hydrazinocarbonyl-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or an appropriate amount of a pharmaceutically acceptable salt thereof.

One aspect of the invention relates to 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl- L-tryptophanamide, or a pharmaceutically acceptable salt, for use in a method of increasing endogenous LH levels in a woman undergoing ART procedures, the method comprising administering to the woman an initial dose of about 0.00003 to about 0.030 mg of 2-(N-acetyl-D-tyrosyl -trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In certain embodiments as described above or below, peak endogenous LH blood levels occur between about 12 hours and about 48 hours after the initial dose.

Another aspect of the invention relates to a method for increasing the level of endogenous LH in a woman undergoing an ART procedure and in need of luteal phase support, comprising administering to the woman an initial dose of from about 0.00003 to about 0.030 mg of Compound 1, or an appropriate amount of its pharmaceutically acceptable salt, after receiving the trigger dose of the oocyte maturation agent indicated by the woman as part of the ART regimen.

In certain embodiments as described above or below, the woman's blood level of endogenous LH is elevated between about 12 hours and about 96 hours after the initial dose compared to the woman's endogenous LH level before the initial dose.

In certain embodiments as described above or below, the woman's endogenous LH blood level is elevated for at least 36 hours after the initial dose compared to the woman's endogenous LH blood level before the initial dose. In some embodiments, the level of endogenous LH in the blood is elevated for about 36 hours to about 16 days, or for about 36 hours to about 12 days.

In certain embodiments described above or below, administration of the initial dose promotes oocyte maturation. In some embodiments, oocyte maturation occurs

- 3 041804 without administration of exogenous hCG or exogenous LH. In other embodiments, oocyte maturation occurs following administration of a GnRH agonist or exogenous hCG. In some embodiments, the yield of mature oocytes is at least 50%.

In certain embodiments of those described above or below, after administration of the initial dose, the woman does not experience one or more of the symptoms selected from the group consisting of ascites, pleural effusion, and decreased renal perfusion. In some embodiments, after administration of the initial dose, the size of the ovary increases to no more than 5 cm in diameter.

In certain embodiments described above or below, the woman does not experience one or more of the symptoms of OHSS after the initial dose. In some embodiments, after administration of the initial dose, the woman experiences no worsening of one or more symptoms of OHSS.

In certain embodiments as described above or below, the initial dose is administered when at least three ovarian follicles at least 14 mm in size are observed by ultrasound, or when at least three ovarian follicles at least 18 mm in size are observed by ultrasound .

In certain embodiments described above or below, the initial dose is administered when the serum estradiol concentration is at least 0.49 nmol/L.

In certain embodiments as described above or below, the method or use further comprises administering FSH from about 5 to about 12 days prior to the initial dose.

In certain embodiments as described above or below, the method or use further comprises administering the GnRH antagonist from about 2 days to about 10 days prior to the initial dose. In some embodiments, the GnRH antagonist is selected from the group consisting of relugolix (relugolix), elagolix (elagolix), cetrorelix, ganirelix, abarelix, nal-blu (nal-blu), antide (antide), azalin B, degarelix, D63153 (ozarelix ), OBE2109 and teverelix. In some embodiments, the method or use further comprises administering the GnRH agonist from about 14 to about 28 days prior to the initial dose. In certain embodiments of those described above or below, the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, histrelin, deslorelin, metererelin, and lecirelin.

In certain embodiments of those described above or below, the initial dose is administered before oocyte retrieval, after oocyte retrieval, before ovulation, or after ovulation. In some embodiments, the initial dose is administered following administration of the GnRH agonist as an oocyte maturation agent.

In certain embodiments as described above or below, wherein the method or use further comprises administering a second dose of about 0.00003 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, the second dose is administered over a period of about 8 to about 60 hours after the initial dose.

In certain embodiments as described above or below, the method or use further comprises administering a third dose of about 0.00003 to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, the third dose is administered over a period of about 8 to about 60 hours after the second dose.

In certain embodiments as described above or below, the methods and uses further comprise administering one to five additional doses of about 0.00003 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, one to five additional doses are administered over a period of about 8 to about 60 hours after the previous additional dose is administered. In some embodiments, one or more initial doses, a second dose, a third dose, or one to five additional doses promote luteal phase support. In some embodiments, one or more initial doses, a second dose, a third dose, or one to five additional doses are administered by injection. In certain such embodiments, the injection is an intramuscular or subcutaneous injection. In certain embodiments of those described above or below, any one or more of the initial doses, the second dose, the third dose, or one to five additional doses is from about 0.0003 to about 0.03 mg.

In certain embodiments of those described above or below, the method or use further comprises administering one or more doses of a progestogen. In certain embodiments described above or below, the method or use does not include the administration of one or more doses of a progestogen.

In certain embodiments of those described above or below, the method or use further comprises retrieving oocytes.

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In certain embodiments described above or below, the woman's pituitary is desensitized to GnRH prior to the initial dose.

In certain embodiments as described above or below, the method or use further comprises implanting an embryo. In some embodiments, implantation occurs within about 2 to about 10 days after the initial dose. In some embodiments, implantation occurs within about 1 to about 7 days after oocyte retrieval. In some embodiments, the embryo is not frozen. In some embodiments, the embryo is implanted in the same menstrual cycle as the oocyte retrieval.

In certain embodiments of those described above or below, the method or use induces ovulation.

In certain embodiments, as described above or below, the woman becomes pregnant through intercourse or IUI after at least the initial dose has been administered. In some embodiments, after at least the initial dose is administered, the woman becomes pregnant and/or gives birth.

In certain embodiments described above or below, the woman is undergoing COS. In some embodiments, the woman has one or more of PCOS, serum anti-Mullerian hormone (AMH) above 15 pmol/l, total antral follicle count (AFF) above 23 on ultrasound, serum estradiol E2 above 3000 pg/ml, or has had one or more previous episodes of OHSS. In some embodiments, the woman is characterized by one or more of the anovulatory cycles, or advanced reproductive age, or is experiencing secondary ovarian failure, oligomenorrhea, amenorrhea, endometriosis, or PCOS.

In certain embodiments described above or below, ART therapy is selected from the group consisting of oocyte donation, oocyte banking, intracytoplasmic sperm injection (ICSI), IVF, embryo transfer process (ET), ovulation induction, and IUI.

One aspect of the invention relates to a method for inducing terminal follicular maturation and early luteinization in a woman in need thereof, said woman undergoing ART procedures, undergoing pituitary desensitization, and having previously received follicle-stimulating hormones as part of ART, comprising administering to the woman an initial dose of from about 0.00003 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof, and after administration of the initial dose, the level of endogenous LH in the woman's blood is increased compared to the level of endogenous LH in the woman's blood before the introduction of the initial dose.

Another aspect of the invention relates to a method for inducing ovulation in a woman in need, wherein said woman is anovulatory infertile and said infertility is not caused by a primary ovarian dysfunction, comprising administering to the woman an initial dose of about 0.00003 to about 0.030 mg of Compound 1, or an appropriate amount its pharmaceutically acceptable salt, and after administration of the initial dose, the level of endogenous LH in the blood of a woman is increased compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Another aspect of the invention relates to 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl- L-tryptophanamide or a pharmaceutically acceptable salt for use in a method of inducing terminal follicular maturation and early luteinization in an ART woman who has undergone pituitary desensitization and has previously received follicle-stimulating hormones as part of ART, the method comprising administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

One aspect of the invention relates to 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl- L-tryptophanamide or a pharmaceutically acceptable salt for use in a method of inducing ovulation in a woman who is anovulatory infertile, said infertility not being caused by a primary ovarian dysfunction, wherein said method comprises administering to the woman an initial dose of 0.00003 to about 0.030 mg of 2-(N -acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or a pharmaceutically appropriate amount thereof acceptable salt.

In certain embodiments described above or below, the woman is at risk for OHSS.

In certain embodiments of those described above or below, the woman is experiencing anovulatory infertility not caused by a primary ovarian dysfunction.

In certain embodiments as described above or below, the methods and uses comprise administering to the woman an initial dose of about 0.001 to about 0.003 mg, about 0.001 to about 0.030 mg, or about 0.0003 to about 0.003 mg of Compound 1, or a pharmaceutically appropriate amount thereof. acceptable salt.

One aspect of the invention relates to the use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-5 041804 prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl -L-arginyl-L-tryptophanamide, or a pharmaceutically acceptable salt thereof, in the manufacture of a drug for increasing endogenous LH levels in a woman undergoing ART procedures at risk of OHSS.

Another aspect of the invention relates to the use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-Lprolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl -L-tryptophanamide, or a pharmaceutically acceptable salt thereof, in the manufacture of a drug for increasing endogenous LH levels in a woman undergoing ART procedures.

One aspect of the invention relates to the use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl -L-tryptophanamide, or a pharmaceutically acceptable salt thereof, in the manufacture of a medicament for inducing final follicular maturation and early luteinization in an ART woman undergoing pituitary desensitization and previously treated with follicle-stimulating hormones as part of ART.

Another aspect of the invention relates to the use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-Lprolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl -L-tryptophanamide, or a pharmaceutically acceptable salt thereof, in the manufacture of a medicament for inducing ovulation in an anovulatory infertile woman, said infertility not being caused by a primary ovarian dysfunction.

Additional embodiments of this invention are described below, where some, but not all, embodiments of the invention are illustrated.

Each implementation option disclosed in this document may be used alone or in combination with any other implementation option disclosed in this document.

Publications, patents and published patent applications referred to in this application are expressly incorporated into this document by reference.

Brief description of graphic materials

Fig. 1 depicts an illustrative diagram of the ART protocol. This scheme should not be considered as restrictive.

In FIG. 2 is a graph depicting the mean plasma concentrations of Compound 1 Monoacetate (API-MA) up to 72 hours across treatment groups when administered to healthy European men as described in Example 5.

Fig. 3 is a graph depicting the mean (± standard deviation [SD]) concentration of compound 1 monoacetate (API-MA) in plasma-time profiles after 2-hour subcutaneous (SC) administration of 0.5 and 1.0 mg/day of API-MA for 14 days in healthy Caucasian males as described in Example 6.

Fig. 4 is a graph depicting mean plasma concentration versus time curves by dosing group: day 1 to 12 hours in Caucasian men with prostate cancer as described in Example 7 using subcutaneous (SC) depot injection.

Fig. 5 is a graph showing mean plasma concentration versus time curves by dosing group: day 2 of month 1 to end of month 3 in Caucasian men with prostate cancer as described in Example 7 using subcutaneous depo injection.

Fig. 6 is a graph depicting mean (± standard deviation (SD)) serum LH concentrations after a single subcutaneous bolus of API-MA in Caucasian men with prostate cancer as described in Example 7.

Fig. 7 is a graph depicting mean (± standard deviation (SD)) serum FSH concentrations after a single subcutaneous bolus of API-MA as described in Example 7.

Fig. 8 is a graph depicting mean serum concentration-time profiles for LH as described in Example 7.

Fig. 9 is a graph depicting mean serum concentration versus time profiles for FSH as described in Example 7.

Fig. 10 is a graph depicting the mean serum LH concentration after administration of API-MA by subcutaneous bolus (day 1) and continuous subcutaneous infusion (days 214) as described in Example 8.

Fig. 11 is a graph depicting the mean serum FSH concentration after administration of API-MA by subcutaneous bolus (day 1) and continuous subcutaneous infusion (SC INF) (days 2-14) as described in Example 8.

Fig. 12 is a graph depicting PH by subjects (N=3) in the 0.5 mg/day API-MA group as described in Example 8.

Fig. 13 is a graph depicting FSH by subject (N=3) in the 0.5 mg/day API-MA group as described in Example 8.

Fig. 14 illustrates the study design described in Example 11, Part 1.

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Fig. 15A, B, and C illustrate changes in LH, FSH, estradiol, and progesterone over hours following administration of 9.6 nmol/kg Kisspeptin-54 (kisspeptin-54, KP54), 0.003 nmol/kg Compound 1, and 0.03 nmol/kg Compound 1 1 healthy women aged 18-35 years, as described in example 11.

Fig. 16A, B and C illustrate changes in LH over 48 hours after administration of 9.6 nmol/kg of kisspeptin-54 (KP54), 0.003 nmol/kg of compound 1, and 0.03 nmol/kg of compound 1 to healthy women aged 18-35 years. , as described in example 11.

Fig. 17 illustrates mean changes in LH for all subjects over 48 hours after administration of 9.6 nmol/kg of kisspeptin-54 (KP54), 0.003 nmol/kg of compound 1, and 0.03 nmol/kg of compound 1 to healthy women aged 18-35 years , as described in example 11.

Fig. 18 illustrates mean changes in LH for all subjects over 48 hours following administration of 0.003 nmol/kg Compound 1 to healthy women aged 18-35 years as described in Example 11.

Fig. 19 illustrates mean changes in LH for all subjects over 48 hours following administration of 0.03 nmol/kg Compound 1 to healthy women aged 18-35 years as described in Example 11.

Fig. 20A and B illustrate changes in FSH and estradiol over 48 hours after administration of 9.6 nmol/kg kisspeptin-54 (KP54), 0.003 nmol/kg compound 1, and 0.03 nmol/kg compound 1 to healthy women aged 18-35 years. , as described in example 11.

Detailed description

Assisted reproductive technologies (ART) are complex, with each cycle of assisted reproductive technologies consisting of several carefully organized stages. If any of these steps are not performed properly, egg fertilization failure or pregnancy pathology may occur. Additionally, the success of ART protocols varies widely among women, which adds to the complexity. Typical ART phases include an initial COS phase to promote and stimulate controlled growth and development of ovarian follicles, followed by the use of a so-called trigger agent to promote/induce final oocyte maturation. In some ART regimens, mature oocytes can then be retrieved from the ovarian follicles, fertilized in vitro or by ICSI, and the embryo(s) transferred to the uterus or, instead of egg retrieval from the ovarian follicles, ovulation occurs and mature oocytes can be fertilized through intercourse or VMI. In a general view, a typical ART scheme is shown in Fig. 1. Since ART procedures are invasive, expensive, and can have negative side effects, it is important to prevent or reduce the possibility of egg fertilization failure or pregnancy pathology.

For example, as schematically shown in FIG. 1, long-term treatment with a GnRH agonist to suppress LH surge begins in the menstrual cycle before the menstrual cycle in which the triggering agent will be administered. GnRH agonist administration may be combined with FSH or FSH/hMG treatment to stimulate follicles or, in the absence of long-term GnRH agonist treatment, the ART treatment protocol may begin with FSH or FSH/hMG treatment. Alternatively, a GnRH antagonist can be used in place of a GnRH agonist to suppress LH surge and is used in combination with a course of FSH or FSH/hMG treatment. In this case, the GnRH antagonist is administered in the same menstrual cycle and after the start of treatment with FSH or the FSH/hMG combination. The course of treatment may then be continued with the administration of a trigger, typically a GnRH agonist, hCG, or as used herein, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. Human chorionic gonadotropin (hCG) has LH-like activity that acts on LH receptors and induces ovulation. Typically 30-62 hours after triggering, oocyte retrieval or ovulation occurs. A woman undergoing ART procedures may then have an IUI or may have intercourse to achieve pregnancy. After the trigger and during the period of PE, IUI, or intercourse, the woman may or may not receive luteal phase support, including, without limitation, administration of a low dose of hCG, a progestogen, estradiol, or Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. .

Disclosed herein are ART methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing. As used herein, compound 1 is 2-(N-acetyl-D-tyrosyl-trans-4hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω -methylL-arginyl-L-tryptophanamide. Compound 2 is a metabolite of Compound 1. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can mimic natural physiology by inducing endogenous LH release during assisted reproduction, thereby possibly increasing the likelihood of successful egg (oocyte) maturation and, in some cases, ovulation at the right time in the cycle without the potential for serious side effects associated with current hormonal stimulation treatment options such as hCG. Previous studies of Compound 1 have been conducted in humans or animals such as rats, dogs and monkeys to evaluate the pharmacokinetic properties of Compound 1 or its efficacy in the treatment of prostate cancer. The bioavailability of compound 1 in rats (66.3%) was significantly

- 7 041804 differed from that for dogs (92.4%). An increase in subcutaneous first pass metabolism induced non-linear pharmacokinetics of compound 1 after a single subcutaneous (SC) administration to rats. Compound 1 demonstrated dose-sub-proportional non-linear pharmacokinetics with a decrease in AUC (area under the curve) after subcutaneous administration in the dose range of 1 and 10 mg/kg in rats. Dose-proportional non-linear pharmacokinetics were observed after subcutaneous administration with limited absorption of Compound 1 at the highest dose level, in contrast to linear pharmacokinetics after intravenous (IV) dosing, indicating increased subcutaneous metabolism with dose escalation. Systemic absorption of compound 1 was restored by co-administration of protease inhibitors subcutaneously, suggesting subcutaneous involvement of proteases in first pass metabolism. The upper human dose given to men by subcutaneous bolus was only approximately 0.008 mg/kg and exposure was dose proportional up to this dose. Subcutaneous infusions were also proportional to approximately 0.1 mg/kg. The depot composition gave a sub-proportional exposure in the range of approximately 0.1 to 0.4 mg/kg. This invention describes the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, in women as an adjuvant in ART. The doses of compound 1 used in this invention are significantly lower than those tested in rats and in men, with a maximum dose of 30 μg or 0.25 μg/kg compared to 1 and 10 mg/kg in rats, and 8 μg/kg and 0.1 to 0.4 mg/kg in men.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, may not only promote maturation, release (ovulation), and retrieval of fresh mature oocytes (or eggs, as used interchangeably herein) from the ovaries, resulting in pregnancy rates similar to or improved over hCG as a trigger, but may also significantly reduce the risk of major side effects such as OHSS compared with hCG and GnRH agonists. Additionally, when compared to currently available trigger agents (particularly hCG-based trigger agents), Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may provide the benefit of a significant reduction in the incidence of OHSS in all patients, including those with elevated levels AMH, or patients with susceptibility to FSH and LH receptor mutations. In addition, compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, can provide luteal phase support by activating the LH surge to a natural peak and for a long duration (>20 hours, mimicking a natural LH surge of 48 hours) with low risk of OHSS. This beneficial effect of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may obviate the need for additional luteal phase support such as daily intramuscular (IM) progesterone injections or additional hCG supplementation, simplifying ART protocols and also allowing fresh embryos to be implanted in during the same menstrual cycle, potentially reducing the time to pregnancy.

Compared to currently available trigger agents, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may provide the benefit of a shorter time to pregnancy. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may provide increased rates of fresh embryo transfer, reduced need for segmentation (freezing of the egg or embryo between retrieval and implantation). Due to the mode of action of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, less adverse effects on the endometrium can be observed compared to current methods. Thus, the endometrium can be ready for implantation (higher receptivity of the endometrium) immediately after retrieval of the egg (oocyte). This may allow implantation to take place in the same menstrual cycle as initiation and retrieval of oocytes. Compared to hCG-based trigger agents (including dual triggers with GnRH agonists), Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may result in less need for a segmented cryopreservation protocol, thereby reducing the number of IVF cycles; reducing the time to pregnancy while maintaining an acceptable pregnancy rate; cost reduction; and reduced side effects such as macrosomia (large for gestational age), placenta accreta, and preeclampsia, all with a significantly lower incidence of OHSS. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may provide safety and efficacy attributes that are advantageous over existing therapies that require segmentation.

The invention also relates to methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to increase endogenous LH levels in a woman undergoing ART procedures such as IVF, ICSI, oocyte donation and preservation, regulation of the menstrual cycle. so that a woman can become pregnant through intercourse or IUI, ovulation induction, and/or during PE. Increasing endogenous LH levels can help both with oocyte maturation and with maintenance of the luteal phase.

This invention further relates to methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to inhibit ovulation and premature oocyte release during the initial phase of COS. Such methods and uses may be applicable to ART protocols that use a gonadotropin releasing hormone (GnRH) agonist or antagonist in the initial phase of COS.

This document contemplates the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, in the manufacture of a medicament for treatment in accordance with any of the methods described herein. Also provided is Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, for use in any of the methods described herein.

Compounds of the invention

As used herein, compound 1 is 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-acn-araginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-Lleucyl-Nω-methyl- L-arginyl-L-tryptophanamide. The molecular formula is C ₅₈ H ₈₀ N ₁₆ O ₁₄ and the molecular weight is 1225.35. Compound 1 is in free form and is represented by the sequence

Ac-D-Tyr-Hyp-Asn-Thr-Phe-AzaGly-Leu-Arg(Me)-Trp-NH ₂ (SEQ ID No. 1), and the structural formula

In certain embodiments, a compound of the invention is a metabolite of compound 1. In certain such embodiments, the metabolite is compound 2 represented by the following structural formula:

In some embodiments, a pharmaceutically acceptable salt of Compound 1 and/or its metabolite is used. Physiologically acceptable, pharmaceutically acceptable, or pharmacologically acceptable compounds and compositions may include materials that are not biologically or otherwise undesirable. For example, the material can be administered to an individual without causing any substantially undesirable biological effects or adverse interactions with any components of the composition containing them. In certain embodiments, the pharmaceutically acceptable salt of Compound 1 and/or its metabolite is a pharmaceutically acceptable acid addition salt. Such salts include, without limitation, salts with inorganic acids (e.g., hydrochloric acid, hydrobromic acid, nitric acid, sulfuric acid, phosphoric acid, and the like) and salts with organic acids (e.g., formic acid, acetic acid, trifluoroacetic acid). , fumaric acid, oxalic acid, tartaric acid, maleic acid, citric acid, succinic acid, malic acid, methanesulfonic acid, benzenesulfonic acid, p-toluenesulfonic acid, and the like). In certain embodiments, the pharmaceutically acceptable salt of Compound 1 and/or its metabolite is a pharmaceutically acceptable base addition salt. Such salts include, without limitation, an inorganic base (for example, alkali metals and alkaline earth metals such as sodium, potassium, calcium, magnesium, ammonia, etc.) or an organic base (for example, trimethylamine, triethylamine, pyridine, picoline, ethanolamine , diethanolamine, triethanolamine, dicyclohexylamine, N,N'-dibenzylethylenediamine, and the like).

As used herein, compound 1 is in the form 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylαlanyl)hydrazinocarbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide monoacetate. For the monoacetate salt, the molecular formula is C ₅₈ H ₈₀ Ni ₆ Oi ₄ -C ₂ H ₄ O ₂ and the molecular weight is 1285.41. The structural formula looks like this:

BUT*""

N**

In the description of this invention, the amount of compound 1 or its metabolite refers to the amount of the free form of compound 1 present in the composition. The term appropriate amount, as used herein, refers to the amount of a pharmaceutically acceptable salt of Compound 1, or its metabolite, required to produce the amount of free form of Compound 1, or its metabolite, specified in the formulation of the composition. One of ordinary skill in the art will understand how to calculate the appropriate amount of the salt of the compound, such as the corresponding amount of the pharmaceutically acceptable salt of Compound 1, given the difference in molecular weight between the free form of the compound and the salt form. For example, 10.0 mg of the free form of the compound would correspond to 10.5 mg of the monoacetate salt.

Compound 1 or a pharmaceutically acceptable salt and pharmaceutical compositions containing compound 1 or a pharmaceutically acceptable salt thereof can be prepared by the methods described in US Pat. Nos. 7,960,348 and 8,404,643, the disclosures of which are incorporated herein by reference.

Compound 1 has been described as a kisspeptin analogue. Kisspeptin, a hypothalamic neuropeptide encoded by the KISS1 gene, is a central regulator of GnRH secretion and a newly discovered hormone vital for normal puberty. Kisspeptin is a human G-protein coupled receptor 54 (GPR54)/KISS1 receptor (KISS1R) peptide agonist ligand (previously known as OT7T175/GPR54). Mutations or knockouts of the KISS1R gene lead to disorders of sexual development. In the hypothalamus, kisspeptin plays a key role in regulating the amount and pulsation of gonadotropin-releasing hormone (GnRH) secretion. Administration of kisspeptin to mammals, including humans, induces the release of GnRH and gonadotropin, and this effect is most likely a direct effect of the peptide on GnRH neurons. GnRH is a key component of the hypothalamic-pituitary-gonadal axis and controls reproductive functions such as spermatogenesis, follicular maturation and ovulation, and steroidogenesis. Thus, kisspeptin is a critical regulator of the hypothalamic-pituitary-gonadal axis through the control of GnRH neurons. There are two modes of GnRH secretion. One mode is the impulse secretion of GnRH, which mainly regulates spermatogenesis, folliculogenesis and steroidogenesis, which is regulated by feedback (negative) steroid hormones. Another regimen is the GnRH surge, which results in an LH surge, which occurs only in women, and induces the final maturation of the oocytes and, ultimately, ovulation. Kisspeptin neurons in the hypothalamus can regulate both modes of GnRH secretion. Pharmacologically, in many species, including humans, acute exposure to kisspeptin can stimulate GnRH gonadotropin secretion, while chronic (high-dose) exposure to kisspeptin can suppress GnRH secretion and the hypothalamic-pituitary-gonadal axis through potential suppressive mechanisms such as desensitization of GnRH receptors. and/or depletion of GnRH reserves. Chronic administration of kisspeptin analogues suppresses natural (intrinsic) GnRH impulses and reduces gonadal functions of the pituitary gland. This may be due to desensitization of GnRH neurons to endogenous kisspeptin stimulation and stimulation of GnRH neurons to continuously release low levels of GnRH.

Kisspeptin-54 has a half-life of 32 minutes and stimulates the release of endogenous GnRH, which then stimulates the release of gonadotropin and subsequently sex hormones. Administration of kisspeptin to healthy male and female volunteers has been shown to significantly increase plasma concentrations of LH, FSH, and testosterone, and subcutaneous administration of kisspeptin to female volunteers has been shown to increase plasma LH in all phases of the menstrual cycle. The kisspeptin effect was greatest in the preovulatory phase, when trigger agents are usually administered, and least in the follicular phase of the cycle. Kisspeptin has also been experimentally tested as a trigger in an ART protocol including a GnRH antagonist and FSH in both the IVF population and the IVF population at high risk of OHSS. Kisspeptin has only been used as a trigger in ART cycles using the GnRH antagonist protocol. Accordingly, increased luteal phase deficiency may be observed in ART protocols using kisspeptin, since GnRH antagonist protocols typically result in luteal phase deficiency when hCG is not the trigger. Kisspeptin was found to stimulate endogenous LH levels, however, the duration of the LH surge was significantly shorter than that observed for hCG or GnRH agonist triggers, necessitating additional exogenous luteal phase support. In the case of kisspeptin-54, the LH surge was resolved within 36 hours. In some women, the full release of LH was not observed, which reduced the yield of oocytes. In addition, higher doses of kisspeptin resulted in a reduced pregnancy rate, and the ideal dose has not yet been determined. Additional studies described in Example 11 (FIGS. 15A and 16A) show that women who received kisspeptin-54 during the follicular phase (when LH levels are least dependent on triggering agents) experienced an increase in LH with a peak at about 4- 6 hours after the administration of kisspeptin as a trigger, with the LH surge lasting less than 14 hours. Despite its shortcomings, studies of kisspeptin-54 show that unfrozen embryo transfer (transfer in the same menstrual cycle) is possible in women at high risk of OHSS.

Compound 1, or a pharmaceutically acceptable salt, has a half-life of up to four hours. As shown in Example 11 (FIGS. 16B, 17, and 18), following a dose of 0.003 nmol/kg Compound 1 (approximately 0.00022 mg) during the follicular phase in women (when LH levels are least affected by triggering agents) , peak serum LH levels are estimated to occur between 14-36 hours post-dose, and the LH surge lasted at least about 48 hours, which is consistent with the duration of the natural LH surge. Thus, the administration of Compound 1, or a pharmaceutically acceptable salt thereof, has the potential not only to initiate the final maturation of oocytes, but also to provide luteal support and thus increase the likelihood of successful implantation. Surprisingly, the LH surge observed for Compound 1 has a curve similar to the natural LH surge, with a broader shape than the LH surge induced by GnRH agonist triggers and potentially longer duration. It was also unexpected that Compound 1 had such a strong effect on LH levels during the follicular phase in women. Because it was more potent than kisspeptin-54, this indicates that compound 1 should also cause a dramatic increase in preovulatory LH levels, potentially exceeding both in magnitude and duration that observed for kisspeptin-54 in the preovulatory phase. phase. As used herein, the pre-ovulatory phase may refer to the period of time 15-16 days before the start of a woman's next predicted period.

Due to the nature of the LH surge observed for compound 1, which more closely mimics the natural surge, it, or its metabolite, may be an ideal agent for inclusion in ART protocols. Administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a trigger may limit the need for luteal phase support. It may also enable the transfer of non-frozen embryos, greatly reducing pregnancy time and costs associated with multiple cycles of ART.

An additional advantage of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above over current treatments is that its effect will depend on the endogenous release of the woman's GnRH pool. This may result in more physiological stimulation of gonadotropins and prevent overstimulation, which is a limitation of current reproductive technologies. Because Compound 1, or its metabolite, stimulates the release of endogenous LH into the woman's circulation, there is a much lower chance of potentially life-threatening OHSS.

Methods of Treatment and Use of Compounds of the Invention

The present invention provides methods and uses for increasing endogenous LH levels in a woman in need, comprising administering to the woman an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing. In some embodiments, the woman is undergoing ART procedures and is at risk for OHSS. In certain such embodiments, after administration of the initial dose, the level of endogenous LH in the woman's blood is increased compared to the level of endogenous LH in the woman's blood before the administration of the initial dose.

In describing this invention, a dose or amount of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing (e.g., from about 0.00003 to about 0.030 mg, from about 0.0003 to about 0.003 mg, from about 0.001 to about 0.003 mg or from about 0.001 to about 0.03 mg of Compound 1, or corresponding amounts of a pharmaceutically acceptable salt thereof) used in any of the methods or uses disclosed herein may be any of the doses or amounts disclosed herein below. Additionally, formulations or pharmaceutical compositions containing Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing used in any of the methods and uses disclosed herein may be any of the formulations or pharmaceutical compositions disclosed herein below. Doses and amounts of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, and formulations or pharmaceutical compositions containing Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above disclosed herein may be administered by any of the routes of administration disclosed in this document.

In the present invention, the level of endogenous LH in the blood of a woman before the introduction of the initial dose can be calculated as the average of five LH values immediately preceding the scheduled day of onset of the LH surge (i.e. 5 days preceding the administration of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of above). The increase will be an increase compared to the level of endogenous LH in the woman's blood before the introduction of the initial dose. The end of the rise occurs when LH levels return to the level of endogenous LH in the woman's blood prior to the initial dose. As used herein, LH peak is the highest LH value, LH amplitude is the difference between the LH peak value and the woman's endogenous LH value before the initial dose, and LH surge gain is the LH peak value divided by the value endogenous LH in the blood of a woman before the introduction of the initial dose. Under COS conditions, the endogenous LH value in a woman's blood before the initial dose is in the range of 2-10 IU/L (IU/L), with a peak LH surge range of 20 to 120 IU/L, (Amplitude = peak value - the level of endogenous LH in the blood of a woman before the introduction of the initial dose). The fold increase is typically from 2-fold to 60-fold. In most women, an increase in LH from 2-fold to 11-fold is expected (when performed under COS or in the preovulatory phase).

As the skilled artisan will appreciate, the success of ART regimens may depend on both the timing and dosage of the administration of various agents throughout the course of treatment and in the various phases of the woman's menstrual cycle. As described herein, various regimens depend on the precise administration of agents, including FSH or FSH/hMG to induce oocyte maturation, as well as the administration of additional agents (e.g., GnRH agonists or antagonists) at specific times in the menstrual cycle and at specific doses to promote maturation. multiple oocytes over a similar period so that after the administration of the triggering agent, fully matured oocytes are available for retrieval prior to premature ovulation for use in e.g. oocyte banking, oocyte donation, IVF, ICSI, etc., or are ovulated and subsequently fertilized by IUI or intercourse within a certain period of time after the planned ovulation. For all such aspects of ART, control of LH levels is important. For example, sufficient LH must be present to stimulate (initiate) the final maturation of numerous oocytes in a given time period and in sufficient quantity to obtain an oocyte yield high enough for successful oocyte retrieval (e.g. sufficient oocyte yield) and thus suitable for ICSI. or IVF. Additionally, in cases where PE is contemplated, particularly in the same menstrual cycle, there must be an elevated LH level sufficient to continue producing progesterone from the corpus luteum to help provide endometrial support (also called luteal support) and thereby increase the likelihood successful embryo implantation, thus leading to a successful pregnancy and live birth. Similarly, in cases where ovulation occurs followed by IUI or intercourse, luteal support and a receptive endometrium are also important for these same reasons. Based on the control of the time of administration and the administered dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, in order to increase the woman's endogenous LH levels to the right amount and at the right time, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can be used safely in the various ART regimens described in this document. As described herein, the use of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, increases the level of endogenous LH in the blood. Since the source of LH is the woman's own pituitary gland and not exogenous LH or an LH receptor agonizing agent, the risk of stimulation of superphysiological amounts of LH (eg, overstimulation), which can lead to

- 12 041804

OHSS or other complications is greatly reduced, while also allowing a high yield of oocytes in oocyte retrieval and support for successful implantation in PE.

This invention includes methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, in assisted reproductive technologies such as IVF, ICSI, oocyte donation and preservation, regulation of the menstrual cycle so that a woman can conceive through intercourse act or intrauterine insemination (IUI), ovulation induction, and / or in the process of PE.

As used herein, in vitro fertilization (IVF) may refer to a method involving the retrieval of a mature ovum, in vitro fertilization of the ovum with sperm, and after undergoing cleavage to a certain extent, inserting the ovum into the uterine cavity. Thus, it may include the processes of ovulation induction, egg retrieval, IVF and culture, and embryo transfer. In IVF, induction of final maturation may allow the retrieval of an egg (oocyte) when the eggs (oocytes) are fully mature. Also, in IVF, the induction of final maturation may be preceded by COS.

Embryo transfer may refer, in IVF processes, to the process of implanting an embryo into the uterine cavity. One to more embryos introduced into the uterine cavity can be implanted into the uterus, thereby possibly leading to pregnancy. The term may also cover frozen embryo transfer and fallopian tube embryo transfer (GIFT) not associated with in vitro fertilization. The process of embryo transfer may refer to the entire period during which the introduction of an embryo or gamete into the uterine cavity, the sequence of processes of implantation of the embryo or gamete into the uterus and pregnancy, the administration of drugs before and after the transfer of the embryo to achieve pregnancy, etc.

Intracytoplasmic sperm injection (ICSI) may refer to a laboratory procedure in which a single sperm cell is harvested using a fine glass needle and injected directly into each egg. In conventional IVF, eggs and sperm are mixed on a cup and the sperm naturally fertilizes the egg. However, to have a chance of achieving this, a large number of actively swimming normal spermatozoa is required. For many couples, the available amount of usable sperm may be very limited, or there may be other factors preventing fertilization, so conventional IVF is not an option, but ICSI may be used. ICSI refers to a laboratory procedure in which a single sperm cell is collected with a thin glass needle and injected directly into each egg. This is done in the laboratory by experienced embryologists using special equipment. This requires a very small amount of spermatozoa, and the ability of spermatozoa to penetrate the egg is not important, since ICSI is used for this. ICSI does not guarantee fertilization, because normal cellular fertilization events must still occur after the sperm is placed in the egg.

In some embodiments of the methods and uses described herein, ART is oocyte donation. In some embodiments of the methods and uses described herein, ART is oocyte preservation. In some embodiments of the methods and uses described herein, ARTs are ICSI. In some embodiments of the methods and uses described herein, ART is IVF. In some embodiments of the methods and applications described herein, ART is a PE process. In some embodiments of the methods and uses described herein, ART is ovulation induction. In some embodiments of the methods and uses described herein, ARTs are IUIs. In some embodiments of the methods and uses described herein, ART is the regulation of the menstrual cycle so that a woman can conceive through intercourse.

Women in the methods and uses described herein may include women seeking to become pregnant. Women in the methods and uses described herein may include women seeking to ovulate. Women in the methods and uses described herein may include women seeking to donate or preserve oocytes (eg, egg donors). Women in the methods and uses described herein may include women seeking to act as surrogate mothers. Women in the methods and uses described herein may include women undergoing COS. Women in the methods and uses described herein may also include women at risk for OHSS. Women in the methods and uses described herein may also include women who are infertile; anovulatory; related to older reproductive age (i.e. over 35 years old); or experiencing secondary ovarian failure, oligomenorrhea, amenorrhea, endometriosis, or polycystic ovary syndrome (PCOS); or combinations of any of the above. Women in the methods and uses described herein may include

- 13,041,804 women experiencing anovulatory infertility not caused by a primary ovarian dysfunction. Women in the methods and uses described herein may include women experiencing anovulatory infertility due to primary ovarian failure (eg, where the woman is unable to complete oocyte maturation or ovulation even under conditions of COS). Women in the methods and uses described herein may include women experiencing anovulatory infertility due to secondary ovarian failure. Female human subject(s) and woman(s) are used interchangeably herein.

Women at risk of OHSS may include, without limitation, women with one or more of the PCOS, serum AMH greater than 15 pmol/L, total AFR greater than 23 on ultrasound, serum estradiol (E2) greater than 3000 pg/mL, or women who have experienced one or more previous episodes of OHSS. In some embodiments, women at risk for OHSS have an AMH greater than 30 pmol/L, in some embodiments, greater than 40 pmol/L. In some embodiments, women at risk of OHSS have a serum E2 estradiol above 3500 pg/mL. In other embodiments, serum E2 is greater than 4000 pg/ml, or greater than 5000 pg/ml. In other embodiments, women at risk for OHSS have a serum E2 estradiol above 6000 pg/mL. Women at risk of OHSS may include, without limitation, women under the age of 30, women with low body weight (thin) or low BMI (body mass index), women with rapidly rising E2 levels, women with a large number of follicles, and combinations of the above.

Controlled ovarian stimulation (COS) and controlled ovarian hyperstimulation (COH) are used interchangeably herein and may refer to medical treatment to induce the development of multiple ovarian follicles to produce multiple oocytes by follicle aspiration. COS may include three basic elements: 1. exogenous gonadotropins to stimulate multifollicular development; 2. co-administration of a gonadotropin-releasing hormone (GnRH) agonist or antagonists to suppress pituitary function and prevent premature ovulation; and 3. initiating final oocyte maturation prior to oocyte retrieval.

The use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as an ART triggering agent or for luteal phase support may result in a shorter time to pregnancy, in particular compared to hCG-based triggering agents, since the need for in segmented freezing protocols that result in the need for more IVF cycles. Initiation, as used herein, may mean the induction, through LH surge, of progression from prophase I to a second delay in metaphase II, which will persist until fertilization. This induction of final maturation initiates the mechanisms that ultimately lead to ovulation and thereby determine ovulation of the oocytes unless artificial oocyte retrieval is done beforehand. As used herein, the luteal phase is the period between ovulation and either the onset of pregnancy or the onset of the menstrual cycle 2 weeks later. The luteal phase is characterized by the formation of the corpus luteum, whose secretion of the steroid hormones estrogen and progesterone depends on stimulation of the LH receptor by LH or hCG. After implantation, the developing blastocyst secretes hCG to maintain corpus luteum function. Intervention during ART, such as the administration of GnRH agonists, can lead to decreased LH levels, causing insufficient progesterone production, luteal phase failure, and possible pregnancy loss. Luteal phase support helps counteract luteal phase deficiency by increasing LH levels and/or stimulating the LH receptor, thereby maintaining corpus luteum function, and/or increasing progesterone and promoting embryo implantation.

The invention also includes methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to reduce the incidence of OHSS. In certain such embodiments, administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above provides a comparable or improved pregnancy rate, reduced pregnancy time, and inhibition of preterm ovulation. Inhibition of premature ovulation may refer to the inhibition of premature follicle/oocyte release (ovulation) (i.e. earlier oocyte maturation and egg retrieval time for IVF or other ART regimen) due to the natural LH surge that induces ovulation. In natural ovulation, egg collection after exogenous collection may be difficult, and IVF or other fertilization methods cannot be performed, so natural ovulation should be avoided in such circumstances.

As described above, OHSS is a syndrome characterized by ovarian enlargement and fluid migration into the extravascular space. Symptoms may include, but are not limited to, abdominal distension and discomfort, hydrothorax, decreased renal perfusion, ovarian-localized edema, ovarian diameter >5 cm or >8 cm, free abdominal fluid, hematocrit >45%, leukocytes >15*109 /l, ALT (alanine aminotransferase) or AST (aspartate aminotransferase

- 14 041804 for) >2x ULN (upper limit of normal), total protein >80 g/l, creatinine >110 µmol/l (mol/L), or, in more severe cases, ascites and/or pleural effusion and their consequences resulting from increased vascular permeability. Complications of OHSS may include, without limitation, haemoconcentration, hypovolemia, and electrolyte imbalances. Mild OHSS can be classified as follows: grade 1 - abdominal distension and discomfort, mild to moderate abdominal pain, bloating or enlarged waist, ovarian tenderness, and sudden weight gain of more than 3 kg (6.6 lbs); and grade 2 - grade 1 disease plus nausea, vomiting and/or diarrhea, and ovarian enlargement up to 5-12 cm. Moderate OHSS can be classified as follows: grade 3 - signs of mild OHSS plus ultrasonographic confirmation of ascites and reduced renal perfusion and function. Severe OHSS can be classified as follows: Grade 4 features of moderate OHSS plus clinical evidence of ascites and/or hydrothorax, labored breathing or dyspnea, severe abdominal pain, severe nausea and vomiting, blood clots in the legs, decreased urination, and tense or enlarged abdomen; and grade 5 - all of the above plus change in blood volume, increased blood viscosity due to hemoconcentration, clotting disorders, and rapid weight gain such as 15 to 20 kilograms (33 to 44 pounds) over a period of five to 10 days. In severe cases, OHSS can lead to death. OHSS may result from increased vascular permeability, usually caused by the effects of exogenous hCG. The methods and uses described herein, which include administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, may be used to treat or prevent OHSS, or to treat or prevent one or more symptoms of OHSS. As used herein, treating or treating a condition, such as a particular disease or disorder, may include treating one or more of the symptoms of the condition and/or preventing the occurrence of the condition. Treatment may include relief of one or more symptoms (e.g., pain), or prevention of one or more symptoms, such as relief or prevention of bloating and discomfort associated with OHSS.

In some embodiments of the methods and uses described herein, a woman may not experience one or more symptoms of OHSS after administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

In some embodiments of the methods and uses described herein, one or more symptoms of OHSS may be treated following an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

In some embodiments of the methods and uses described herein, after administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman may not experience worsening of one or more symptoms of OHSS.

In some embodiments of the methods and uses described herein, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, one or more of the symptoms of OHSS may be relieved.

In some embodiments of the methods and uses described herein, upon administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, a woman may not experience one or more symptoms selected from the group consisting of ascites, pleural effusion, and reduced renal perfusion.

In some embodiments of the methods and uses described herein, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, one or more symptoms selected from the group consisting of ascites, pleural effusion, and decreased renal perfusion.

In some embodiments of the methods and uses described herein, upon administration of an initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the size of the ovary increases to no more than 5 cm in diameter. In some embodiments of the methods and uses described herein, upon administration of an initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the size of the ovary increases to no more than 8 cm in diameter.

The use of hCG causes extensive luteinization of the ovary, which releases large amounts of estrogen, progesterone, and local cytokines. The production of VEGF (vascular endothelial growth factor) by follicles under the influence of hCG can increase vascular hyperpermeability underlying OHSS. In the methods and uses described herein, the use of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, can inhibit or reduce VEGF and thus reduce OHSS-associated vascular permeability. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may have the ability to induce ovulation in the COS without increasing hCG or VEGF levels. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may also have the ability to provide luteal phase support

- 15 041804 without increasing VEGF levels.

Although GnRH agonists, when used as trigger agents, are associated with a lower risk of OHSS, they also result in significantly lower pregnancy rates. The use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a trigger agent may result in a higher pregnancy rate compared to GnRH trigger agonists. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a trigger agent may result in a higher pregnancy rate compared to hCG triggers. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a triggering agent may result in a biochemical pregnancy rate greater than 40%. Biochemical pregnancy may refer to serum hCG >10 mIU/mL 11 days after embryo transfer. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a trigger agent may result in a clinical pregnancy rate greater than 40%. Clinical pregnancy may refer to an intrauterine gestational sac with a heartbeat on ultrasound at 6 weeks gestation. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a trigger agent may result in live birth rates greater than 40%. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, can induce ovulation without producing excess VEGF in the follicles, without sustained hCG elevation and LH receptor overstimulation, and without excess estrogen, progesterone, or local cytokines, thus possibly reducing risk OHSS. Oocyte maturation and ovulation induction with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above as a triggering agent may ultimately result in a pregnancy rate comparable to or higher than that observed with currently available triggering agents. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may also relieve the symptoms of polycystic ovarian syndrome (PCOS) as they may stimulate normalization of ovulation in patients with ovarian dysfunction.

In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above for luteal phase support in ART may significantly reduce the risk of OHSS compared to conventional therapy (i.e. luteal phase support with hCG). Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may provide luteal phase support without excess VEGF production in the follicles and without excess estrogen, progesterone, or local cytokines, thereby possibly reducing the risk of OHSS. The use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, for luteal phase support may also ultimately result in a pregnancy rate comparable to, or higher than, that observed with currently available luteal phase support agents. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, for luteal phase support may result in biochemical pregnancy rates greater than 40%. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, for luteal phase support may result in clinical pregnancy rates greater than 40%. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, for luteal phase support, may result in live birth rates greater than 40%.

The present invention provides methods and uses for increasing pregnancy rates following ovulation induction with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, instead of hCG trigger agents or GnRH agonists. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, is administered to the woman as a trigger agent, with administration following the COS phase. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can effectively promote follicular maturation and induce ovulation (i) without increasing total blood VEGF levels, or (ii) by increasing total VEGF levels for less than 24 hours after introductions. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is used to support the luteal phase to increase pregnancy rates.

The invention also provides methods and uses for increasing pregnancy rates following ovulation induction with a triggering agent, comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, for

- 16 041804 luteal phase support. In some embodiments, administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above follows or occurs at substantially the same time as initiation. In certain such embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may provide luteal phase support (i) without increasing total blood VEGF levels, or (ii) by increasing total VEGF levels for less than 24 hours after introductions.

Progestogens, such as progesterone, may or may not be administered in connection with the methods and uses described herein. In some embodiments, progesterone is not administered in the methods and uses described herein. Indeed, one possible advantage of administering multiple doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is that a progestogen may not be required to support the luteal phase. This greatly simplifies ART protocols, as many require daily administration of a progestogen such as progesterone, often by injection. Sometimes, administration of a progestogen, such as progesterone, is required for 3 months or more after egg retrieval. Eliminating or reducing the requirement for a progestogen, such as progesterone, by administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, will alleviate the burden of ART and simplify protocols.

The invention further provides methods and uses for reducing the likelihood of developing OHSS following ovulation induction with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, in lieu of an hCG trigger regimen. In some embodiments, the method or use follows the COS phase and involves administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to the woman as a trigger agent that can effectively promote follicular maturation and induce ovulation. In some embodiments, the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a triggering agent (i) does not increase total blood VEGF levels, or (ii) increases total VEGF levels for less than 24 hours after administration.

This invention further contemplates reducing the likelihood of developing OHSS after ovulation induction by using Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to support the luteal phase. In certain such embodiments, administration of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above follows or occurs substantially at the same time as initiation. In some embodiments, use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above for luteal phase support (i) does not increase total blood VEGF levels, or (ii) increases total VEGF levels for less than 24 hours post-administration.

The invention provides methods for using Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to increase endogenous LH levels in a woman undergoing ART procedures in need thereof, in which the level of endogenous LH in the woman's blood is elevated at least about 36 hours after administration of the initial dose , compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments, the woman's endogenous LH blood level is elevated at least about 24 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared to the woman's endogenous LH blood level prior to the initial dose. In some embodiments, at least about 40 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's endogenous LH blood level is elevated relative to the woman's endogenous LH blood level prior to the initial dose. In some embodiments, at least about 44 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's blood level of endogenous LH is elevated relative to the woman's endogenous LH blood level prior to the initial dose. In some embodiments, at least about 48 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's endogenous LH blood level is elevated relative to the woman's endogenous LH blood level prior to the initial dose. In some embodiments, at least about 52 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's blood level of endogenous LH is elevated relative to the woman's endogenous LH blood level prior to the initial dose.

The invention also provides methods for using Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to increase endogenous LH levels in a woman undergoing ART procedures in need thereof, in which the maximum level of endogenous LH in the blood is observed at least about 12 hours after introductions beginning

- 17 041804 dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, peak endogenous LH blood levels occur between about 12 hours and about 48 hours after the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, peak endogenous LH blood levels occur between about 12 hours and about 36 hours after the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, peak endogenous LH blood levels occur between about 12 hours and about 24 hours after the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, peak endogenous LH blood levels occur between about 12 hours and about 18 hours after the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 14 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 16 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 18 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 20 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 22 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 24 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels are observed approximately 28 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 32 hours after administration of the initial dose. In some embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, peak endogenous LH blood levels occur approximately 36 hours after administration of the initial dose.

The invention provides methods and uses for increasing the level of endogenous LH in a woman undergoing ART procedures and in need of luteal phase support, including administering to the woman an initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, after receiving the indicated trigger dose of an oocyte maturation agent by the woman within the ART scheme. An oocyte maturation agent, or trigger agent, can be used to promote final oocyte maturation in ART regimens prior to oocyte retrieval (eg IVF, ICSI) or prior to ovulation as part of a treatment such as PCOS when, after ovulation, IUI or intercourse is timed by a certain time to maximize the chance of fertilization of the egg. Oocyte maturation agents may include, for example, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, hCG, recombinant luteinizing hormone (rLH), or a GnRH agonist. In some embodiments, the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, histrelin, deslorelin, metererelin, lecirelin, or pharmaceutically acceptable salts of any of the above. In some embodiments, one or more doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may be administered to a woman in need of luteal phase support before oocyte retrieval, after oocyte retrieval, or both before and after oocyte retrieval. Similarly, for ART regimens not involving oocyte retrieval, one or more doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may be administered to a woman in need of luteal phase support before ovulation, after ovulation, or both before and after ovulation.

In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 12 hours and about 96 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction

- 18 041804 I eat the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 12 hours and about 84 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 12 hours and about 72 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 12 hours and about 60 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 12 hours and about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 14 hours and about 84 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is elevated between about 14 hours and about 72 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is elevated between about 14 hours and about 60 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 14 hours and about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 24 hours and about 84 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 24 hours and about 72 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is elevated between about 24 hours and about 60 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased between about 24 hours and about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is elevated for at least about 36 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is elevated for at least about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. One potential advantage of the methods and uses described herein over current triggers is the convenience of increasing LH levels over 36 hours. If ovulation is likely to occur approximately 48 hours after the initial dose of Compound 1, its metabolite or pharmaceutical

- 19 041804 a logically acceptable salt of any of the above, the methods and uses described herein will be useful for scheduling (logistics of scheduling) ART appointments compared to the current standard of care. Currently, if the trigger is administered at approximately 8 pm, the egg is collected 36 hours later (8 am). If ovum retrieval can be performed with a high degree of probability after about 48 hours, as contemplated by the present invention, patients will receive a trigger and ovum retrieval may take place during normal business hours. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is elevated for at least about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 16 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 12 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 11 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 10 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 9 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 8 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 7 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased for from about 36 hours to about 6 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 5 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 4 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 3 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 36 hours to about 2 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

In some embodiments of the methods and applications described herein, the level

- 20 041804 the endogenous LH level in the woman's blood is increased for from about 48 hours to about 16 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the woman's blood before the introduction of the initial dose . In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased for from about 48 hours to about 12 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 11 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 10 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased for from about 48 hours to about 9 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 8 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 7 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 6 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the woman's blood is elevated from about 48 hours to about 5 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 4 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 48 hours to about 3 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 16 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 12 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 11 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the woman's blood is elevated from about 24 hours to about 10 days after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

- 21 041804 compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 9 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 8 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased for from about 24 hours to about 7 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 6 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 5 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 4 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 3 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein, the level of endogenous LH in the blood of a woman is increased from about 24 hours to about 2 days after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can be used to promote the maturation of eggs or ova, which can then be sequentially retrieved and fertilized by IVF or ICSI and then transplanted into the uterus (PE). Alternatively, the eggs or ovum can be released from the ovaries (induced ovulation) and subsequently fertilized through intercourse or IUI. For proper and successful oocyte retrieval, oocyte maturation and induction of these oocytes at the right time must first occur. The COS phase may help prevent premature ovulation, and the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above as a triggering agent may promote oocyte maturation and allow retrieval, in vitro fertilization, and embryo transfer, or induce oocyte release (ovulation) and allow fertilization through intercourse or IUI. As such, administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, can result in a pregnancy rate close to or higher than current rates, a shorter time to pregnancy, and a reduced risk of developing OHSS.

The present invention provides methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to promote oocyte maturation and induce ovulation in assisted reproductive technology (ART). The methods and uses described herein may allow the use of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to promote oocyte maturation and induce ovulation in ART without the administration of another initiating agent such as hCG, exogenous LH, and/or an agonist. GnRH. In some embodiments of the methods and uses described herein, an initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, promotes oocyte maturation. In some embodiments of the methods and uses described herein, oocyte maturation occurs without the administration of exogenous hCG or exogenous LH. In certain such embodiments, the yield of mature oocytes is at least 50%. In certain such

- 22 041804 embodiments, the yield of mature oocytes is at least 75%. Oocyte yield may refer to the percentage of mature (metaphase 2; M2) oocytes obtained from follicles having a size of 14 mm on the last ultrasound scan prior to triggering. Oocytes can be independently classified as M2 by the presence of the first directional body and rounded ooplasm. In some embodiments, administration of a trigger containing Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above results in an increased number of mature oocytes compared to hCG initiation.

As used herein, a mature oocyte is one that has reached metaphase stage II (M2). Oocytes are classified as M2 by the presence of the first directional body and rounded ooplasm. Oocytes resume meiotic maturation in response to a midcycle LH surge. This final oocyte maturation can be medically induced with hCG or a GnRH agonist. The former binds the LH receptor, while the GnRH agonist promotes the release of endogenous gonadotropin stores from the pituitary gland. The resumption of meiosis (the so-called nuclear maturation) occurs 14-18 hours after the start of the LH surge; meiosis I is completed within 35 hours and the oocytes reach metaphase stage II (M2). At the same time, in response to the LH surge, cumulus cells demonstrate almost complete expansion by 20:00; the mature cumulus-oocyte complex then detaches from the follicle wall prior to ovulation. Although nuclear maturation and cumulus expansion are closely related, it remains unclear whether different levels of LH are necessary to regulate the two processes.

In accordance with the present invention, in some embodiments, administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, promotes oocyte maturation and induces (initiates) ovulation in a woman (i) without increasing VEGF levels, or (ii) by increasing such levels for a period of less than 24 hours.

This invention provides methods and uses for inducing ovulation using compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain such embodiments, the method or use may include the steps of administering to the woman an amount of FSH, or an analogue thereof, in combination with a GnRH agonist or antagonist to facilitate the initial phase of COS ART. In some embodiments, the initial phase of COS may be followed by the administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, as a trigger agent that effectively promotes oocyte maturation and induces ovulation. In some embodiments, administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, as a triggering agent that effectively promotes oocyte maturation and induces ovulation (i) without increasing total blood VEGF levels, or (ii) by increasing total VEGF levels for less than 24 hours. In some embodiments in the COS phase, the GnRH antagonist or GnRH agonist may be administered in an amount and for a period of time sufficient to act to suppress ovulation in a controlled manner, and is administered in combination with FSH or FSH analogs. In some embodiments, the GnRH antagonist is relugolix.

The invention also provides methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, for inducing ovulation in an anovulatory cycling woman suffering from secondary ovarian failure. Causes of secondary ovarian failure occur in the hypothalamus and pituitary gland when they fail to hormonally stimulate the ovaries and subsequent ovarian function. In some embodiments, the method or use comprises the steps of (1) pre-administering human gonadotropins to the subject, and (2) administering to the subject Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing.

The invention also provides methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to provide luteal phase support in an anovulatory cycling woman suffering from primary ovarian dysfunction. Primary ovarian dysfunction is the depletion or dysfunction of the ovarian follicles with the cessation of menstruation before the age of 40 years. Primary ovarian failure is the National Institutes of Health's preferred term for primary ovarian failure because ovarian function is often irregular or unpredictable. Because 5-10% of women with primary ovarian failure experience spontaneous egg fertilization and delivery, primary ovarian failure can be distinguished from natural menopause and can also be described as reduced ovarian reserve. In some embodiments, the methods and applications may further include a PE process.

The present invention provides methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, for inducing terminal follicular maturation and early luteinization in a woman undergoing an ART procedure, said woman having undergone pituitary desensitization and previously received follicle stimulating hormones. In certain such embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's blood level of endogenous LH is elevated relative to the woman's endogenous LH level prior to the initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the woman is at risk of OHSS. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, at least about 36 hours after administration, the level of endogenous LH in the blood of a woman is increased compared with the level of endogenous LH in the blood of a woman before the initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the maximum level of endogenous LH in the blood is observed at least about 12 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the maximum level of endogenous LH in the blood occurs between about 12 hours and about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the level of endogenous LH in the woman's blood is increased between about 12 hours and about 96 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the woman's blood before administration initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the level of endogenous LH in the woman's blood is increased for at least about 36 hours after administration compared with the level of endogenous LH in the woman's blood before the initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the level of endogenous LH in the woman's blood is increased for at least about 24 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared with the level of endogenous LH in the woman's blood before administration initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the level of endogenous LH in the blood is increased for from about 36 hours to about 16 days after the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, in which the administration of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, is intended to induce final maturation

- 24 041804 follicles and early luteinization in a woman undergoing ART procedures and said woman has undergone pituitary desensitization and previously received follicle-stimulating hormones, the level of endogenous LH in the blood is increased for from about 36 hours to about 12 days after the initial dose of compound 1, its metabolite or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the level of endogenous LH in the blood is increased for from about 24 hours to about 16 days after the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce terminal follicular maturation and early luteinization in a woman undergoing ART procedures and said woman has undergone desensitization pituitary gland and previously received follicle-stimulating hormones, the level of endogenous LH in the blood is increased for from about 24 hours to about 12 days after the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

The present invention provides methods and uses comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, for inducing ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction. In certain such embodiments, following administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's blood level of endogenous LH is elevated relative to the woman's endogenous LH level prior to the initial dose.

In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the woman has a risk of OHSS. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, by at least about 36 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, the woman's endogenous LH blood level is elevated relative to the woman's endogenous LH blood level prior to the initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, by at least about 24 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman's endogenous LH blood level is elevated relative to the woman's endogenous LH blood level prior to the initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is intended to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the maximum the level of endogenous LH in the blood is observed at least about 12 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is intended to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the maximum the level of endogenous LH in the blood is observed between about 12 hours and about 48 hours after administration of the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level endogenous LH in a woman's blood is elevated between about 12 hours and about 96 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above

- 25 041804 listed, compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. In some embodiments of the methods and uses described herein wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level The woman's endogenous LH level is elevated for at least about 36 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared to the woman's level of endogenous LH prior to the initial dose. In some embodiments of the methods and uses described herein wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level endogenous LH in the blood is elevated for at least about 36 hours to about 16 days after the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing is intended to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level endogenous LH in the blood is elevated for at least about 36 hours to about 12 days after the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level The woman's endogenous LH level is elevated for at least about 24 hours after administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, compared to the woman's level of endogenous LH before the initial dose. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level endogenous LH in the blood is elevated for at least about 24 hours to about 16 days after the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, wherein administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is to induce ovulation in a woman who is anovulatory infertile and the infertility is not due to a primary ovarian dysfunction, the level endogenous LH in the blood is elevated for at least about 24 hours to about 12 days after the initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

Larger follicle size at the time of initiation may improve the yield of mature oocytes. The invention provides for the administration of doses of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, with the initial dose being administered when at least three ovarian follicles of at least about 14 mm in size are observed by ultrasound. In some embodiments of the methods and uses described herein, initial doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, are administered when at least three ovarian follicles of at least about 18 mm are observed by ultrasound.

The invention also provides for the administration of doses of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, with the initial dose administered after ovulation. In some embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered prior to ovulation.

In some embodiments, the methods and uses described herein include oocyte retrieval. The invention provides for the administration of doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the initial dose being administered after oocyte retrieval. In some embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, is administered prior to oocyte retrieval.

In some embodiments of the methods and uses described herein, prior to administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, the female pituitary gland is desensitized to GnRH prior to administration.

- 26 041804 initial dose. In certain embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, is administered when the serum estradiol concentration is at least about 0.49 nmol/L. In certain embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, is administered when the serum estradiol concentration is at least about 0.91 nmol/L.

In some embodiments of the methods and uses described herein, the embryo is implanted following an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain such embodiments, implantation occurs within about 2 to about 10 days after the initial dose, e.g., about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, about 8 days, about 9 days, or about 10 days. In some embodiments of the methods and uses described herein, embryo implantation occurs within about 1 to about 7 days after oocyte retrieval, e.g., about 1 day, about 2 days, about 3 days, about 4 days, about 5 days , about 6 days, or about 7 days. In certain embodiments of the methods and uses described herein, the embryo is fresh (ie, the embryo is not frozen). In certain such embodiments, the embryo is implanted in the same menstrual cycle as the oocyte retrieval. Due to the mode of action of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, there may be less adverse effects on the endometrium compared to current treatments. Thus, the endometrium can be ready for implantation (higher endometrial receptivity) immediately after egg retrieval. By not using hCG or GnRH agonist trigger agents (including GnRH agonist dual triggers), Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may result in less need for a segmented cryopreservation protocol, thereby reducing number of IVF cycles; reducing the time to pregnancy while maintaining an acceptable pregnancy rate; reducing costs; and reducing side effects such as macrosomia (large size for gestational age), the risk of placenta accreta, and the risk of preeclampsia, with significantly lower rates of OHSS. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may provide safety and efficacy attributes that are advantageous over current therapies that require segmentation.

Since non-frozen embryos can be used in the uses and methods of this invention, the invention also contemplates reducing the time to pregnancy following ovulation induction by Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, instead of using hCG as a triggering agent or GnRH agonist. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to the woman as a trigger agent and administration follows the COS phase. In certain such embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can effectively promote follicular maturation and induce ovulation (i) without increasing total blood VEGF levels, or (ii) by increasing total VEGF levels for less than 24 hours after administration.

The invention also provides methods and uses for reducing the time to pregnancy following ovulation induction with a trigger agent, comprising administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, to support the luteal phase. In some embodiments, administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above follows or occurs at substantially the same time as initiation. In certain such embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may provide luteal phase support by (i) without increasing total blood VEGF levels, or (ii) by increasing total VEGF levels for less than 24 hours after administration. .

The invention provides methods and uses comprising administering doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, the method or use inducing ovulation. In certain such embodiments, the woman conceives through intercourse or IUI after administration of at least an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. Administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to initiate oocyte release without oocyte retrieval may result in a predictable time of ovulation, with an interval from administration to ovulation ranging from 30 to 62 hours post-administration or 36 to 48 hours post-administration. introductions. This can make it possible to conveniently schedule intercourse or IUI at the time of ovulation, maximizing the chances of fertilizing an egg. The introduction of compound 1, its

- 27 041804 metabolite or pharmaceutically acceptable salt of any of the above may also help women who have problems with ovulation ovulate and conceive through intercourse or IUI. In some embodiments, triggering oocyte release using Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be a fallback option for women in need of IUI in whom PH control has proven difficult or unreliable. In some embodiments, initiation of oocyte release using Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be used when LH monitoring does not detect an LH surge by cycle day 18 (where cycle day 1 is the first day of prior menses) and there is ovarian follicle larger than 20 mm.

In some embodiments of the methods and uses described herein, after administration of at least an initial dose of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, the woman conceives or gives birth. In some embodiments, the woman gives birth by caesarean section. In some embodiments, the woman gives birth vaginally.

In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.001 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.001 mg to about 0.003 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.0003 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.003 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.00006 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.00009 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.00015 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.0006 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.0009 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.0015 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.006 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof, is from about 0.00003 mg to about 0.009 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00003 mg to about 0.015 mg.

In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.030 mg. In some embodiments of the methods and applications described in this document

- 28 041804 mente, the amount or dose administered or used, such as the initial dose, of compound 1 or the corresponding amount of its pharmaceutically acceptable salt is from about 0.0003 mg to about 0.0006 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.0009 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.0015 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.006 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.009 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.015 mg.

In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.003 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.003 mg to about 0.006 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.003 mg to about 0.009 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.003 mg to about 0.015 mg.

In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0003 mg to about 0.003 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0006 mg to about 0.003 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.0009 mg to about 0.003 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0015 mg to about 0.003 mg.

In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or a corresponding amount of a pharmaceutically acceptable salt thereof is from about 0.00006 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.00009 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose of compound 1, or a corresponding amount of a pharmaceutically acceptable salt thereof, is from about 0.00015 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0006 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0009 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.0015 mg

- 29 041804 to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.006 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.009 mg to about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is from about 0.015 mg to about 0.030 mg.

In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or the corresponding amount of a pharmaceutically acceptable salt thereof is about 0.00003 mg. In some embodiments of the methods and uses described herein, the amount or dose, such as starting dose, of Compound 1 or the corresponding amount of its pharmaceutically acceptable salt administered or used is about 0.030 mg. In some embodiments of the methods and uses described herein, the amount or dose, such as starting dose, of Compound 1, or the corresponding amount of a pharmaceutically acceptable salt thereof, administered or used is about 0.0003 mg. In some embodiments of the methods and uses described herein, the amount or dose, such as starting dose, of compound 1 or the corresponding amount of a pharmaceutically acceptable salt thereof administered or used is about 0.003 mg. In some embodiments of the methods and uses described herein, the amount or dose, such as starting dose, of Compound 1, or the corresponding amount of a pharmaceutically acceptable salt thereof, administered or used is about 0.00005 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as starting dose, of Compound 1 or the corresponding amount of a pharmaceutically acceptable salt thereof is about 0.0005 mg. In some embodiments of the methods and uses described herein, the amount or dose, such as starting dose, of Compound 1 or the corresponding amount of a pharmaceutically acceptable salt thereof administered or used is about 0.005 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is about 0.010 mg. In some embodiments of the methods and uses described herein, the amount or dose, such as starting dose, of Compound 1, or the corresponding amount of a pharmaceutically acceptable salt thereof, administered or used is about 0.0001 mg. In some embodiments of the methods and uses described herein, the amount or dose administered or used, such as an initial dose, of Compound 1 or an appropriate amount of a pharmaceutically acceptable salt thereof is about 0.001 mg.

Doses of Compound 1 or corresponding amounts of a pharmaceutically acceptable salt may thus also be expressed, for example, in nmol/kg (eg as expressed in Example 11) or in μg/kg. For example, 0.003 nmol/kg and 0.03 nmol/kg correspond approximately to 0.0037 μg/kg and 0.037 μg/kg of the free form of Compound 1, respectively. For a 60 kg woman, a dose of 0.003 nmol/kg would be approximately 0.22 µg, or 0.00022 mg, and a dose of 0.03 nmol/kg would be 2.2 µg, or 0.0022 mg.

In some embodiments of the methods and uses described herein, the amount or dose of Compound 1 metabolite, such as Compound 2, or a corresponding amount of a pharmaceutically acceptable salt thereof, administered or used is from about 0.00002 mg to about 0.020 mg. In some embodiments of the methods and uses described herein, the amount administered or used or the dose of a Compound 1 metabolite, such as Compound 2, or a corresponding amount of a pharmaceutically acceptable salt thereof, is from about 0.001 mg to about 5 mg. In some embodiments of the methods and uses described herein, the amount or dose of Compound 1 metabolite, such as Compound 2, or a corresponding amount of a pharmaceutically acceptable salt thereof, administered or used is from about 0.00002 mg to about 0.002 mg. In some embodiments of the methods and uses described herein, the amount or dose of Compound 1 metabolite, such as Compound 2, or an appropriate amount of a pharmaceutically acceptable salt thereof, administered or used is about 0.0002 mg to about 0.002 mg. In some embodiments of the methods and uses described herein, the amount administered or used or the dose of a Compound 1 metabolite, such as Compound 2, or a corresponding amount of a pharmaceutically acceptable salt thereof, is from about 0.00002 mg to about 5 mg. In some embodiments of the methods and uses described herein, the amount administered or used or

- 30 041804 the dose of a metabolite of Compound 1, such as Compound 2, or a corresponding amount of a pharmaceutically acceptable salt thereof, is about 0.0002 mg to about 0.020 mg.

Combination Therapies

As briefly described above, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be administered in combination with other agents used in ART. Such agents may include agents used in the COS phase (eg, FSH, hMG, GnRH agonists or antagonists, and combinations thereof); initiating agents such as GnRH agonists, hCG, and combinations thereof; and hCG, estradiol, a progestogen such as progesterone, and combinations thereof to support the luteal phase prior to embryo transfer, IUI, or sexual intercourse. Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may also be administered in combination with each other. In some embodiments, multiple consecutive doses of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, may be administered in the methods and uses described herein. Therapeutically effective amounts of agents used in combinations may vary depending on the route of administration, the selected agent and the condition of the woman. As used herein, a therapeutically effective amount may refer to an amount of a compound sufficient to cause a particular effect (eg, initiation of final oocyte maturation, endometrial support, etc.).

The administration of such agents in combination is typically carried out over a period of time (usually minutes, hours, days or weeks, depending on the combination chosen). In certain embodiments, the agents are administered sequentially, that is, each agent is administered at a different time, and the administration of such agents, or at least two of the agents, is (performed) substantially simultaneously. Substantially simultaneous administration may be accomplished, for example, by administering to the woman a single injection having a predetermined ratio of each agent, or several separate injections of each of the agents. Sequential or substantially simultaneous administration of each agent may be by any suitable route, including, without limitation, oral, intravenous, subcutaneous, intramuscular routes, and direct absorption through mucosal tissues. The agents may be administered by the same route or by different routes. Alternatively, for example, all therapeutic agents may be administered by intravenous injection. In the case of injection, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be combined with other agents used in ART to reduce the number of injections given to a patient.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be used in combination with a number of therapies included in ART. Such therapies include, without limitation, those used in the COS phase of the ART process (e.g., follicle growth agents such as FSH, hMG, etc., which are used to stimulate oocyte development and growth, and GnRH agonists or antagonists, which are used to control ovarian stimulation and prevention of premature ovulation, or a combination of any of the above).

In some embodiments of the methods and uses described herein, FSH is administered prior to administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, FSH is administered from about 5 days to about 12 days prior to administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain such embodiments, the FSH administration is about 5 days, about 6 days, about 7 days, about 8 days, about 9 days, about 10 days, about 11 days, or about 12 days before administration of the initial dose of Compound 1, its a metabolite; or a pharmaceutically acceptable salt of any of the above.

In some embodiments of the methods and uses described herein, the GnRH antagonist is administered prior to the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, the GnRH antagonist is administered from about 2 days to about 10 days prior to administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, such as from about 3 days to approximately 5 days prior to administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain such embodiments, administration of the GnRH antagonist is about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 7 days, about 8 days, about 9 days, or about 10 days prior to administration. initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

In some embodiments of the methods and uses described herein, the GnRH agonist is administered prior to the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, the GnRH agonist is administered from about 14 days to about 28 days prior to administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, such as from about 14 days to about 17 days prior to administration of an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain such embodiments, administration of the GnRH agonist is about 14 days, about 15 days, about 16 days, about 17 days, about 18 days, about 19 days, about 20 days, about 21 days, about 22 days, about 23 days , about 24 days, about 25 days, about 26 days, about 27 days, or about 28 days prior to administration of the initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

With regard to the GnRH agonists previously mentioned as those that can be used in combination with Compound 1, its metabolite or a pharmaceutically acceptable salt of any of the above, in ART in the COS phase to prevent premature ovulation, such agents include the following: superactive GnRH agonist ( gonadotropin-releasing hormone) such as leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, gistrelin, deslorelin, metererelin, lecirelin, or pharmaceutically acceptable salts of any of the above, and the like; or a GnRH antagonist such as cetrorelix, ganirelix, abarelix, nal blue, antide, azalin B, degarelix, D63153 (ozarelix), OBE2109, teverelix, elagolix, relugolix, or pharmaceutically acceptable salts of any of the above, and the like. In some embodiments, the GnRH agonist for preventing premature ovulation in the COS phase is leuprorelin acetate.

In some embodiments, the GnRH antagonist to prevent premature ovulation in the COS phase may be relugolix, or a pharmaceutically acceptable salt thereof. Relugolix is K-(4-(1-(2,6-difluorobenzyl)-5-((dimethylamino)methyl)-3-(6-methoxy-3-pyridazinyl)-2,4dioxo-1,2,3, 4-tetrahydrothieno[2,3-d]pyrimidin-6-yl)phenyl)-N'-methoxyurea and is represented by the formula

Relugolix is active when administered orally and antagonizes GnRH via GnRH receptors present in basophils (secretory cells) of the anterior pituitary gland and inhibits GnRH-stimulated LH and FSH secretion by these cells. In some embodiments of the methods and uses described herein, the dose of relugolix, or a corresponding amount of a pharmaceutically acceptable salt thereof, is from about 20 mg to about 120 mg, such as 80 mg. In some embodiments of the methods and uses described herein, the dose of relugolix, or a corresponding amount of a pharmaceutically acceptable salt thereof, is less than about 20 mg, less than about 40 mg, less than about 80 mg, or less than about 120 mg.

Relugolix, or a pharmaceutically acceptable salt, is an orally available GnRH antagonist that may be useful in the COS phase of ART when used with FSH or FSH/hMG to prevent premature ovulation by suppressing natural LH surge. This may then allow Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above to be used as a trigger to promote oocyte maturation for subsequent retrieval, in vitro fertilization, PE, ICSI, oocyte donation and banking, intercourse, or IUI, or ovulation induction.

Relugolix, when used in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above (as a trigger agent), may reduce the incidence of OHSS, increase the pregnancy rate, and shorten the time to pregnancy when compared to administration of GnRH agonists instead of relugolix. Additionally, in some embodiments, an injectable composition comprising Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can be used with oral FSH and an oral GnRH antagonist such as relugolix, possibly allowing an ART cycle to be predominantly oral. (making the ART cycle predominantly oral),

- 32 041804 in contrast to the current protocol, which includes a large number of injections.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may also be used with other initiating agents for oocyte maturation (ie, oocyte maturation agents). In some embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be administered following administration of a GnRH agonist as an oocyte maturation agent. In some embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be administered concurrently with the administration of a GnRH agonist as an oocyte maturation agent. In some embodiments of the methods and uses described herein, an initial dose of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be administered prior to administration of the GnRH agonist as an oocyte maturation agent. In some embodiments, the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, histrelin, deslorelin, metererelin, lecirelin, or pharmaceutically acceptable salts of any of the above. In some embodiments, oocyte maturation occurs following administration of a GnRH agonist. In certain such embodiments, the yield of mature oocytes is at least 50%. In certain such embodiments, the yield of mature oocytes is at least 75%. As noted above, oocyte yield can refer to the percentage of mature oocytes collected from the number of 14 mm follicles on the last ultrasound scan prior to triggering. The present invention contemplates that by administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, in combination with a GnRH agonist as an oocyte maturation agent, a woman may not experience worsening of one or more symptoms of OHSS. The invention also contemplates that by administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, in combination with a GnRH agonist as an oocyte maturation agent, one or more symptoms of OHSS can be treated.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can be used with hCG as an oocyte maturation agent. In some embodiments, hCG is administered concurrently with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, hCG is administered prior to compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, hCG is administered following administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, hCG is administered within 24 hours of administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, hCG is administered within 48 hours of administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. Ovulation will occur between 38 and 40 hours after a single hCG injection, and transvaginal oocyte retrieval is typically performed between 34 and 36 hours after hCG injection, just before the moment of rupture of the follicles. In certain embodiments, oocyte maturation occurs after administration of exogenous hCG. In certain such embodiments, the yield of mature oocytes is at least 50%. In certain such embodiments, the yield of mature oocytes is at least 75%. As noted above, oocyte yield can refer to the percentage of mature oocytes collected from the number of 14 mm follicles on the last ultrasound scan prior to triggering. The present invention contemplates that by administering Compound 1, its metabolite or a pharmaceutically acceptable salt of any of the above, in combination with hCG as an oocyte maturation agent, a woman may not experience worsening of one or more symptoms of OHSS. The invention also contemplates that by administering Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, in combination with hCG as an oocyte maturation agent, one or more symptoms of OHSS can be treated. In some embodiments, hCG used in ART may be recombinant or isolated from urine.

In some embodiments of the methods and uses described herein, recombinant luteinizing hormone (rLH) can be used to achieve oocyte maturation. In certain such embodiments, rLH is administered concurrently with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, rLH is administered after Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, rLH is administered prior to compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above.

The invention provides for the use of compound 1, its metabolite or a pharmaceutically acceptable salt of any of the above, with a combination of both GnRH agonist and hCG as oocyte maturation agents. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered concomitantly with a GnRH agonist

- 33 041804 and hCG. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered prior to the GnRH agonist and hCG. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered after the GnRH agonist and hCG.

In some embodiments of the methods and uses described herein, Compound 1, or a pharmaceutically acceptable salt thereof, is used in combination with a Compound 1 metabolite, such as Compound 2, or a pharmaceutically acceptable salt thereof, as oocyte maturation agents. In certain embodiments of the methods and uses described herein, multiple doses of Compound 1, or a pharmaceutically acceptable salt thereof, such as two doses, are used to mature oocytes. In certain embodiments of the methods and uses described herein, multiple doses of a Compound 1 metabolite, such as Compound 2, or a pharmaceutically acceptable salt thereof, such as two doses, are used to mature oocytes.

In addition, compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above can be used in the process of PE, with intercourse, or IUI, or in ovulation induction, in combination with an implantation or pregnancy promoter, such as luteal phase support with estradiol , a progestogen such as progesterone, low dose hCG, or a combination thereof. In some embodiments of the methods and uses described herein, a combination of estradiol and a progestogen, such as progesterone, is administered to support the luteal phase. In some embodiments of the methods and uses described herein, a progestogen, such as progesterone, is administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to support the luteal phase. In some embodiments of the methods and uses described herein, estradiol is administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to support the luteal phase. In some embodiments of the methods and uses described herein, estradiol and a progestogen, such as progesterone, are administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to support the luteal phase. In some embodiments of the methods and uses described herein, one or more doses of a progestogen, such as progesterone, is administered to support the luteal phase. In certain embodiments, a progestogen, such as progesterone, may be administered from the time of oocyte retrieval to 12 weeks post retrieval. In some embodiments, a progestogen, such as progesterone, may be administered upon retrieval of oocytes. In some embodiments, a progestogen, such as progesterone, may be administered from the time of oocyte retrieval to one week after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to two weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to three weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to four weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to five weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to six weeks post retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to seven weeks post retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to eight weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to nine weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to ten weeks after retrieval. In some embodiments, a progestogen, such as progesterone, may be administered between the time of oocyte retrieval and up to eleven weeks after retrieval.

In some embodiments of the methods and uses described herein, a progestogen, such as progesterone, is administered to support the luteal phase following administration of a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, estradiol is administered to support the luteal phase following the administration of a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments of the methods and uses described herein, a progestogen such as progesterone and estradiol are administered to support the luteal phase following administration of a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above.

To support the luteal phase, in some embodiments, the methods and uses described herein involve the use of natural progesterone (P4) preparations, including dydrogesterone, medrogesterone, and progesterone itself. In some implementations

- 34 041804 methods and applications described in this document, P4 can be administered orally, intramuscularly (IM) or vaginally. An intramuscular progestogen such as progesterone can be prepared in sesame oil, coconut oil or peanut oil and the dosage is 50mg once a day. There are several vaginal formulations of a progestogen, such as progesterone, including gels, suppositories, and inserts. Prometrium (Prometrium®) can be used as a vaginal preparation, with the recommended dose of 200 mg for vaginal administration 3 times a day. Crinone® vaginal gel 8% (Columbia Laboratories Inc.; Livingston, New Jersey) can be applied once daily and contains 90 mg of a progestogen such as progesterone. One hundred milligrams of endometrin (Endometrin®) (Ferring Pharmaceuticals Inc.; Suffern, New York) can be administered vaginally 2 or 3 times a day.

In certain embodiments of the methods and uses described herein, a low dose of hCG is administered to support the luteal phase. In some embodiments of the methods and uses described herein, a low dose of hCG is administered to support the luteal phase following a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with a progestogen, such as progesterone, to support the luteal phase after a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with estradiol to support the luteal phase after a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In certain embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with a progestogen such as progesterone and estradiol to support the luteal phase after a Compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above.

In some embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, to support the luteal phase. In certain embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, and a progestogen, such as progesterone, to support the luteal phase. In certain embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, and estradiol to support the luteal phase. In certain embodiments of the methods and uses described herein, a low dose of hCG is administered in combination with Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, a progestogen such as progesterone, and estradiol to support the luteal phase.

In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after the woman has received an hCG-based trigger. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after the woman has received a GnRH agonist trigger. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after the woman has received both hCG and a GnRH trigger agonist. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after a woman has received a trigger based on Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after the woman has received both a GnRH agonist trigger and a compound 1-based trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after the woman has received both an hCG-based trigger and a Compound 1-based trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above. In some embodiments, compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered to support the luteal phase after the woman has received an hCG trigger, a GnRH agonist trigger, and a compound 1 trigger, its metabolite, or a pharmaceutically acceptable salt of any of the above.

In some embodiments of the methods and uses described herein, Compound 1, or a pharmaceutically acceptable salt thereof, is used in combination with a Compound 1 metabolite, such as Compound 2, or a pharmaceutically acceptable salt thereof, to support the luteal phase. In certain embodiments of the methods and uses described herein, multiple doses of Compound 1, or a pharmaceutically acceptable salt thereof, such as two doses, are used to support the luteal phase. In certain embodiments of the methods and uses described herein, multiple doses of a Compound 1 metabolite, such as Compound 2, or a pharmaceutically acceptable salt thereof, such as two doses, are used to support the luteal phase.

Compound 1, or a pharmaceutically acceptable salt thereof, has the advantage that it can be used not only as an ovulation trigger, but can be re-administered one or more times to provide additional LH to support the luteal phase. This may reduce the need for progesterone injections and supplements. Current ART protocols typically use a GnRH trigger agonist followed by a low dose of hCG to support the luteal phase, but this increases the risk of OHSS. Administration of one or more doses of Compound 1, or a pharmaceutically acceptable salt thereof, may reduce the risk of OHSS present in current ART protocols and act as a trigger for oocyte maturation and/or luteal phase support. Multiple doses of Compound 1, or a pharmaceutically acceptable salt thereof, may reduce the risk of OHSS by preventing an increase in serum VEGF, thereby reducing vascular permeability.

In some embodiments, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered in combination with a protease inhibitor. In certain such embodiments, the administration of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above in combination with a protease inhibitor is intended to support the luteal phase. In certain such embodiments, the composition administered contains both Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, and a protease inhibitor. In some embodiments, a composition containing both Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, and a protease inhibitor is intended for immediate release, delayed or sustained release, or delayed release. In certain such embodiments, the composition may exhibit an immediate release profile. In some embodiments, a composition containing both Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, and a protease inhibitor may exhibit a sustained or sustained release profile. In some embodiments, a composition containing both Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, and a protease inhibitor may exhibit a delayed release profile. In some embodiments, a composition containing Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above is administered separately from a composition containing a protease inhibitor. Possible protease inhibitors that can be used in the methods and uses of the invention include, without limitation, 4-(2aminoethyl)benzenesulfonyl fluoride hydrochloride (AEBSF), EDTA, bestatin, E-64, leupeptin such as leupeptin hemisulfate monohydrate, aprotinin, (2S,3S)-3-carboxyoxirane-2-carbonyl]-L-leucine(4-guanidinobutyl)amide hemihydrate; and salts of any of the above.

Compositions, dosing and administration

This invention provides compositions or pharmaceutical compositions containing compound 1, its metabolite or pharmaceutically acceptable salt of any of the above, and a pharmaceutically acceptable excipient or carrier for use in the methods and uses disclosed herein. In ART, Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be administered as a formulation or pharmaceutical composition with one or more pharmaceutically acceptable carriers or excipients. The amount of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above administered may vary according to the weight, age, and medical condition of the woman. Therapeutically effective amounts of Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing used herein may vary depending on the route of administration, the chosen agent, and the condition of the woman.

Compound 1, or a pharmaceutically acceptable salt thereof, is stable and can be stored at 4°C, unlike many peptide drugs, which must be stored and reconstituted at -20°C.

Compositions of the invention can be formulated to provide different release rates such as immediate release, sustained or sustained release, or delayed release. In some embodiments, the compositions may exhibit an immediate release profile. In some embodiments, the compositions may exhibit a sustained or sustained release profile. In some embodiments, the compositions may exhibit a delayed release profile.

The carrier or excipients of the compositions of the invention may be a mixture of excipients, in amounts that may optimize the effectiveness of the composition. Excipients include, for example, various organic or inorganic excipients or carrier materials.

- 36 041804

Compositions containing Compound 1, its metabolite or a pharmaceutically acceptable salt of any of the above may be administered by injection, for example intravenously (IV), intramuscularly (IM) or subcutaneously (SC). In some embodiments, the injection is intramuscular (IM). In other embodiments, the injection is subcutaneous (SC). In some embodiments, the subcutaneous injection is a bolus. In some embodiments, the subcutaneous injection is an infusion. Injection typically involves delivery of a predetermined amount of the liquid composition using a hypodermic needle and syringe or other injection devices known to those skilled in the art. Examples of injections may also include infusion and intravenous devices. The injection may be given immediately or over a period of time.

An injection dosage form containing compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may be based on water or oil as a diluent or carrier. Examples of diluents or carriers include, without limitation, water for injection, alcohol, propylene glycol, macrogol, sesame oil, corn oil, olive oil, vegetable oil, cottonseed oil, corn oil, and the like. In some embodiments, the diluent or carrier is water for injection. Alternatively, the dosage form for injection may be in the form of an emulsion, suspension or solution. The injectable dosage form may contain other ingredients such as dispersing agents, dissolution aids, suspending agents, stabilizers, surfactants, solubilizers, surfactants, buffering agents, isotonicity agents, pH adjusters and soothing agents. Suitable dispersing agents include, without limitation, Tween 80® (Atlas Powder Company USA), HCO 60™ (Nikko Chemicals Co., Ltd.), polyethylene glycol, carboxymethylcellulose, sodium alginate, hydroxypropylmethylcellulose, dextrose, and dextrin. In some embodiments, the dispersing agent is dextrose. Suitable stabilizers include, without limitation, ascorbic acid and sodium pyrosulfite. Suitable surfactants include, without limitation, polysorbate 80 and macrogol. Suitable solubilizers include, without limitation, glycerol and ethanol. Suitable buffering agents include, without limitation, phosphoric acid or its alkali metal salts, citric acid or its alkali metal salts, acetates and carbonates. Suitable isotonicity agents include, without limitation, sodium chloride, glycerine, potassium chloride, mannitol, sorbitol, glycerol, and glucose. In some embodiments, the isotonicity agent is mannitol. Suitable pH adjusters include, without limitation, hydrochloric acid, acetic acid, and sodium hydroxide. In some embodiments, the pH adjuster is acetic acid. Suitable preservatives include, without limitation, ethyl p-hydroxybenzoate, benzoic acid, methyl paraben, propyl paraben, and benzyl alcohol. Suitable solubilizers include, without limitation, concentrated glycerol and meglumine. Suitable dissolution aids include, without limitation, propylene glycol and sucrose. Suitable sedatives include, without limitation, glucose and benzyl alcohol. Examples of dissolution aids include polyethylene glycol, propylene glycol, D-mannitol, benzyl benzoate, ethanol, trisaminomethane, cholesterol, triethanolamine, sodium carbonate, sodium citrate, and the like. Examples of suspending agents include surfactants such as stearyl triethanolamine, sodium lauryl sulfate, lauryl amino propionate, lecithin, benzalkonium chloride, benzethonium chloride, glycerol monostearate, etc.; hydrophilic polymers such as polyvinyl alcohol, polyvinylpyrrolidone, sodium carboxymethylcellulose, methylcellulose, hydroxymethylcellulose, hydroxyethylcellulose, hydroxypropylcellulose, etc. Other excipients that may be used include, for example, lactose, sucrose, starch, corn starch, crystalline cellulose, silicic anhydride, light anhydrous silicic acid, and the like.

Other additives such as preservatives, antioxidants and coloring agents may also be used. Possible preservatives include, without limitation, paraoxybenzoic acid ester, chlorobutanol, benzyl alcohol, phenethyl alcohol, dehydroacetic acid, sorbic acid, and the like. Possible antioxidants include, without limitation, sulfite, ascorbic acid, and the like. Possible coloring agents include, without limitation, oxides of iron (3) (ferric oxide).

In some embodiments, an injectable composition of the invention comprises Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the foregoing, mannitol, acetic acid, and water for injection. In certain such embodiments, the composition further comprises glucose and/or dextrose.

In some embodiments, an injectable composition of the invention may be adjusted to a pH of 2 to 12, preferably 2.5 to 8.0, by adding a pH adjusting agent.

The amount administered with an injectable formulation may be effective in promoting egg maturation in ARTs such as IVF, ICSI, oocyte donation and preservation, regulation of the menstrual cycle so that a woman can conceive through intercourse or IUI, ovulation induction, and /or PE process. In some embodiments of the composition

- 37 041804 for injection according to the invention can be administered as a single dose. In some embodiments, injections may be performed when release and retrieval of mature oocytes is desired, such as during the trigger phase, prior to ovarian oocyte retrieval, IVF, ICSI, oocyte donation and preservation, regulation of the menstrual cycle so that a woman can conceive through intercourse. act or IUI, and implantation of a fertilized embryo into the uterus. In some embodiments, the injectable compositions of the invention may be administered as a single dose. In some embodiments, the injectable compositions of the invention may be administered as a divided dose. In some embodiments, two doses of an injectable composition of the invention may be administered. In some embodiments, the second injectable dose is administered over a period of about 8 to about 60 hours after the initial dose. In some embodiments, three doses of an injectable composition of the invention may be administered. In some embodiments, the third injectable dose is administered over a period of about 8 to about 60 hours after the second dose. In some embodiments, a third injectable dose is administered followed by one to five additional injectable doses. In some embodiments in which a third injectable dose is administered followed by one to five additional injectable doses, the one to five additional doses are administered over a period of about 8 to about 60 hours after the previous dose.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may also be administered in depot formulations. Depot injectable forms can be prepared by forming microencapsulated drug matrices in biodegradable polymers such as polylactide-polyglycolide, poly(orthoesters), poly(anhydrides), and (poly)glycols such as PEG. Depending on the ratio of drug to polymer and the nature of the particular polymer used, the rate of drug release can be controlled. Injectable depot compositions can also be prepared by incorporating the drug into liposomes or microemulsions compatible with body tissues.

The injectable compositions of the invention may be sterilized, for example, by filtration through a bacteria-retaining filter, or by incorporating sterilizing agents into sterile solid composition forms which may be dissolved or dispersed in sterile water or other sterile injectable medium immediately prior to use.

Compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above may also be administered in an intranasal composition. The composition may be in the form of a liquid so that it can be injected into the nostrils, although a semi-solid composition such as an intranasal cream is possible. Liquid intranasal compositions may be in the form of a solution, suspension or emulsion, and may be aqueous or non-aqueous. The ingredients listed above for an injectable dosage form may also be used in accordance with methods known to those skilled in the art to prepare an intranasal composition.

An amount of compound 1, its metabolite, or a pharmaceutically acceptable salt of any of the above, administered intranasally, may be effective in promoting egg maturation in ARTs such as IVF, ICSI, oocyte donation and preservation, regulation of the menstrual cycle so that a woman can conceive through sexual intercourse. intercourse or IUI, ovulation induction, and/or PE process. In some embodiments, the intranasal compositions of the invention may be administered as a single dose. In some embodiments, intranasal administration may be performed when release and retrieval of mature oocytes is desired, e.g., in the trigger phase, prior to ovarian oocyte retrieval, IVF, ICSI, oocyte donation and preservation, regulation of the menstrual cycle so that the woman can conceive through sexual intercourse or IUI and implantation of the fertilized embryo into the uterus. In some embodiments, the intranasal compositions of the invention may be administered as a single dose. In some embodiments, the intranasal compositions of the invention may be administered as a divided dose. In some embodiments, two doses of the intranasal composition of the invention may be administered. In some embodiments, the second intranasal dose is administered over a period of about 8 to about 60 hours after the initial dose. In some embodiments, three doses of the intranasal composition of the invention may be administered. In some embodiments, the third intranasal dose is administered over a period of about 8 to about 60 hours after the second dose. In some embodiments, a third intranasal dose is administered, followed by one to five additional intranasal doses. In some embodiments in which a third intranasal dose is administered, followed by one to five additional intranasal doses, the one to five additional doses are administered over a period of about 8 to about 60 hours after the previous dose.

In addition, conventional additives such as a preservative, an antioxidant, a coloring agent, a sweetener, an adsorbent, a wetting agent, etc., can be appropriately used in suitable amounts, in all dosage forms, if necessary. Possible preservatives include, for example, p-hydroxybenzoates, paraoxybenzoic acid ester, chlorobutanol, benzyl alcohol, phenethyl alcohol, dehydroacetic acid, sorbic acid, ethyl poxybenzoate, benzoic acid, methylparaben, propylparaben, and the like. Possible antioxidants include, for example, sulfite, ascorbic acid, α-tocopherol, and the like.

Dosage forms containing Compound 1 and its pharmaceutically acceptable salts are disclosed, for example, in US Patent Application Publication Nos. 2012/0302508, 2013/0210742, 2011/0312898 and 2011/0212890, the disclosures of which are incorporated herein by reference. Publications also disclose various indications and end uses of Compound 1.

In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.001 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.001 mg to about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.0003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, the formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.00006 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.00009 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.00015 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.0006 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.0009 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.0015 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.006 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.009 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00003 mg to about 0.015 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.0006 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.0009 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.0015 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.006 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.009 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.015 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.003 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical

- 39 041804 compositions according to the invention contain from about 0.003 mg to about 0.006 mg of compound 1 or the corresponding amount of its pharmaceutically acceptable salt. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.003 mg to about 0.009 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, the compositions or pharmaceutical compositions of the invention contain from about 0.003 mg to about 0.015 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0003 mg to about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0006 mg to about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0009 mg to about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0015 mg to about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00006 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00009 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00015 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0006 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0009 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0015 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.006 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.009 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.015 mg to about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.00003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.030 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.0003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.003 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.00005 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.0005 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.005 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.010 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.0001 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain about 0.001 mg of Compound 1, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00002 mg to about 0.020 mg of a Compound 1 metabolite, such as Compound 2, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some variants of

- 40 041804 formulations or pharmaceutical compositions according to the invention contain from about 0.001 mg to about 5 mg of a metabolite of compound 1, such as compound 2, or an appropriate amount of its pharmaceutically acceptable salt. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00002 mg to about 0.002 mg of a Compound 1 metabolite, such as Compound 2, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0002 mg to about 0.002 mg of a Compound 1 metabolite, such as Compound 2, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.00002 mg to about 5 mg of a Compound 1 metabolite, such as Compound 2, or an appropriate amount of a pharmaceutically acceptable salt thereof. In some embodiments, formulations or pharmaceutical compositions of the invention contain from about 0.0002 mg to about 0.020 mg of a Compound 1 metabolite, such as Compound 2, or an appropriate amount of a pharmaceutically acceptable salt thereof.

In some embodiments, the formulation or pharmaceutical composition of the invention may be administered as a single dose. In some embodiments, the formulation or pharmaceutical composition of the invention may be administered as a divided dose. In some embodiments, the initial dose of the formulation or pharmaceutical composition of the invention provides luteal phase support. In some embodiments, the initial dose of the formulation or pharmaceutical composition of the invention is a trigger for oocyte maturation. In some embodiments, two doses of a formulation or pharmaceutical composition of the invention may be administered. A second dose of a formulation or pharmaceutical composition of the invention may result in more viable oocytes and better pregnancy rates for some women. In addition, a second dose may be required to achieve full LH surge and to obtain mature oocytes, and may be administered both for donation and oocyte bank establishment and in IVF/ICSI cycles. In some embodiments, a second dose may be needed to support the luteal phase. In certain such embodiments, a second dose may be required in an ART protocol with non-frozen embryo transfer. In some embodiments, the second dose is administered over a period of about 8 to about 60 hours after the initial dose. In certain such embodiments, the second dose is administered over a period of about 8 to about 12 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 8 to about 16 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 8 to about 24 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 8 to about 32 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 8 to about 40 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 8 to about 48 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 8 to about 54 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 12 to about 16 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 12 to about 24 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 12 to about 32 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 12 to about 40 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 12 to about 48 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 12 to about 54 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 24 to about 36 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 24 to about 48 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 24 to about 60 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 36 to about 48 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 36 to about 60 hours after the initial dose. In some embodiments, the second dose is administered over a period of about 48 to about 60 hours after the initial dose.

In some embodiments, three doses of a formulation or pharmaceutical composition of the invention may be administered. In some embodiments, a third dose of a formulation or pharmaceutical composition of the invention provides luteal phase support. In some embodiments, the third dose is administered over a period of about 8 to about 60 hours after the second dose. In certain such embodiments, the third dose is administered over the course of

- 41 041804 period from about 8 to about 12 hours after the second dose. In some embodiments, the third dose is administered over a period of about 8 to about 16 hours after the second dose. In some embodiments, the third dose is administered over a period of about 8 to about 24 hours after the second dose. In some embodiments, the third dose is administered over a period of about 8 to about 32 hours after the second dose. In some embodiments, the third dose is administered over a period of about 8 to about 40 hours after the second dose. In some embodiments, the third dose is administered over a period of about 8 to about 48 hours after the second dose. In some embodiments, the third dose is administered over a period of about 8 to about 54 hours after the second dose. In some embodiments, the third dose is administered over a period of about 12 to about 16 hours after the second dose. In some embodiments, the third dose is administered over a period of about 12 to about 24 hours after the second dose. In some embodiments, the third dose is administered over a period of about 12 to about 32 hours after the second dose. In some embodiments, the third dose is administered over a period of about 12 to about 40 hours after the second dose. In some embodiments, the third dose is administered over a period of about 12 to about 48 hours after the second dose. In some embodiments, the third dose is administered over a period of about 12 to about 54 hours after the second dose. In some embodiments, the third dose is administered over a period of about 24 to about 36 hours after the second dose. In some embodiments, the third dose is administered over a period of about 24 to about 48 hours after the second dose. In some embodiments, the third dose is administered over a period of about 24 to about 60 hours after the second dose. In some embodiments, the third dose is administered over a period of about 36 to about 48 hours after the second dose. In some embodiments, the third dose is administered over a period of about 36 to about 60 hours after the second dose. In some embodiments, the third dose is administered over a period of about 48 to about 60 hours after the second dose.

In some embodiments, a third dose of the formulation or pharmaceutical composition of the invention is administered, followed by one to five additional doses. In some embodiments, one to five additional doses of the composition or pharmaceutical composition of the invention administered after the third dose of the composition or pharmaceutical composition of the invention provide luteal phase support. In some embodiments, one to five additional doses of the composition or pharmaceutical composition of the invention administered after the third dose of the composition or pharmaceutical composition of the invention are administered after oocyte retrieval. In some embodiments in which a third dose of a formulation or pharmaceutical composition of the invention is administered followed by one to five additional doses, the one to five additional doses are administered over a period of about 8 to about 60 hours after the previous dose. In certain such embodiments, one to five additional doses are administered over a period of about 8 to about 12 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 8 to about 16 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 8 to about 24 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 8 to about 32 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 8 to about 40 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 8 to about 48 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 8 to about 54 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 12 to about 16 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 12 to about 24 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 12 to about 32 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 12 to about 40 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 12 to about 48 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 12 to about 54 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 24 to about 36 hours after administration of the pre

- 42 041804 marching dose. In some embodiments, one to five additional doses are administered over a period of about 24 to about 48 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 24 to about 60 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 36 to about 48 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 36 to about 60 hours after the previous dose. In some embodiments, one to five additional doses are administered over a period of about 48 to about 60 hours after the previous dose.

The following are examples of embodiments of the invention, which should not be construed as limiting.

Examples

In the figures and examples, the term API-FB (active pharmaceutical ingredient - free base) is used in relation to the free form of compound 1. The term API-MA (active pharmaceutical ingredient - monoacetate) is used in relation to the monoacetate salt form of compound 1.

Additionally, in the figures and examples, dosage values refer to the amount of API-FB present in the composition. One skilled in the art will understand how to calculate the amount of API-FB given the difference in molecular weight between API-FB and API-MA. For example, 10.0 mg of API-FB would correspond to 10.5 mg of API-MA.

The baseline levels indicated in the examples refer to hormone levels in an individual prior to administration of one or more doses of a compound of the invention.

The activity of API-MA was studied in vitro and in vivo in a series of pharmacological studies.

In vitro receptor binding studies demonstrated that API-MA has a high affinity for human KISS1R, with an average IC ₅₀ value of 230 pmol/L. In the human GPR54 calcium mobilization assay, the agonist activity of API-MA was at a concentration that produced a half maximum effective concentration (EC ₅₀ ) of 266 pmol/l. Kisspeptin EC ₅₀ (45-54) was 314 pmol/L.

Example 1. In vitro pharmacology.

Binding affinity of API-MA to KISS1R.

The binding affinity of API-MA to membrane fractions of KISS1R-expressing recombinant cells was analyzed by competitive binding assay. Various concentrations of API-MA and ¹²⁵ I-kisspeptin (45-54) were incubated with membrane fractions of KISS1R-expressing recombinant rat, dog, monkey, and human cells.

The results of receptor binding studies showed that the binding affinity of API-MA for KISS1R varied between the species studied, with IC ₅₀ values ranging from 230 to 870 pmol/l. For recombinant Chinese Hamster Ovary cells (cell line h175-KB34) expressing human KISS1R, the _IC50 value for API-MA was approximately 2.5 times higher than for kisspeptin (45-54), which is a peptide consisting of C-terminal amino acid residues of kisspeptin, with an IC ₅₀ value of 230 pmol/l for API-MA versus 93 pmol/l for kisspeptin (45-54).

Example 2 Effect of API-MA on Intracellular Ca ²⁺ Levels in Chinese Hamster Ovary Cells Expressing KISS1R.

The effect of API-MA on intracellular Ca ²⁺ mobilization in KISS1R expressing recombinant cells was assessed by analysis using a plate reader with fluorometric imaging. API-MA increased intracellular Ca ²⁺ levels in dihydrofolate reductase negative Chinese hamster ovary cells expressing rat, dog, monkey or human KISS1R in a concentration dependent manner. The EC ₅₀ values for API-MA in cells expressing the rat, canine, simian or human type receptor were 632, 2010, 74.0 and 266 pmol/L, respectively. The reference compound, kisspeptin (45-54), showed EC ₅₀ values of 310, 1680, 78.7, and 314 pmol/l, respectively. The ratios of EC ₅₀ values for API-MA and kisspeptin (45-54) were 2.0, 1.2, 0.94, and 0.85 for cells expressing each type of receptor, respectively. These results suggest that the agonist activity of API-MA against KISS1R is as strong as that of kisspeptin (45-54).

Secondary pharmacodynamics.

In a series of binding assays using 127 enzymes and radioligands, API-MA, at a concentration of 10 µmol/l, did not show any significant inhibitory effect in these enzyme and receptor binding assays.

Example 3 Pharmacokinetics and drug metabolism in animals.

The pharmacokinetics (PK) of API-MA was studied in rats, dogs and monkeys. Following subcutaneous (SC) administration, API-MA was rapidly absorbed and API-MA bioavailability was good across species (>55%).

- 43 041804

In vitro distribution and metabolism studies.

The in vitro distribution coefficients of [ ¹⁴ C]API-MA in blood cells at concentrations of 0.01, 0.1, 1 and 10 μg/ml for API-FB (free form) were 7.8%, 8.0%, 7.1%, and 4.8% for rats, 2.4%, 2.0%, 1.6% and 1.2% for dogs, and 2.0%, 0.0%, 0.0% , and 0.5% for humans, respectively. These results indicate that the distribution coefficients of API-FB in blood cells were low and almost constant over the concentration range from 0.01 to 10 μg/ml as API-FB in rats, dogs and humans. In vitro plasma protein binding ratios for [ ¹⁴ C]API-FB in rats, dogs, monkeys and humans were determined by ultracentrifugation. In addition, protein binding to human serum albumin (HSA), α1-acid glycoprotein (AGP), and HSA/AGP was studied. The results of these studies indicated that plasma protein binding to API-FB was moderate for all species studied (ranging from 55.3% to 73.3%). In rats and dogs, there was a slight decrease in the binding coefficient in the concentration range between 0.1 and 1.0 μg/ml API-FB. In monkeys and humans, binding was independent of drug concentration ranging from 0.01 to 10 μg/ml API-FB. The binding coefficient in the HSA/AGP mixture was lower than in human plasma and, unlike human plasma, the coefficient tended to decrease in a concentration dependent manner, suggesting that API-FB binds to more than albumin and CH-acid glycoprotein. but also with other human plasma protein(s).

CYP inhibition by API-MA was assessed in vitro using recombinant CYPs; data (IC ₅₀ values >10 µg/l) indicate that API-MA is unlikely to be an inhibitor of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6 or CYP3A4.

Pharmacokinetics in rats.

The pharmacokinetics (PK) of API-MA was studied in rats after subcutaneous (SC) and intravenous (IV) administration. Pharmacokinetic profile of API-MA in rats is presented in table. 1.

After subcutaneous administration of API-MA at doses of 1 and 10 mg/kg, the increase in the maximum observed plasma concentration (C _max ) for API-FB in plasma was sub-proportional to the dose (an increase of about 2.3 times). The mean values were 381.3 and 284.6 ng/ml, respectively. On the other hand, the increase in area under the plasma concentration versus time curve from 0 to 24 hours (AUC( ₀ _ ₂₄ )) for API-FB after 10 mg/kg subcutaneous administration was >2.5-fold less than observed at 1 mg/kg. Mean values for doses of 10 and 1 mg/kg were 309 and 804 ng-h/ml, respectively. The reason why the values of C _max and AUC in rats were not proportional to the dose remains unknown. However, the time to reach the maximum observed plasma concentration (T _max ) was approximately constant for all studied doses; values ranged from 0.3 to 0.9 hours. The terminal elimination half-life (T _1/2 ) has not been determined due to the limited number of data points.

After intravenous (IV) administration of API-MA at a dose of 1 mg/kg, the plasma concentration after 5 minutes (C ₅ min) was 2672.3 ng/ml. The concentration then decreases biphasically, with a T _1/2 value of 0.5 h for the alpha phase. T _1/2 for the beta phase was not calculated due to the limited number of data points. The AUC( ₀ _ ₂₄ ) value was 1457 ng-h/mL.

The bioavailability of the 1 mg/kg subcutaneous (SC) dose of API-MA in rats was good (55.3%).

The linearity of pharmacokinetics for API-MA was also studied in rats after intravenous administration. Plasma C _5min and AUC( ₀ _ ₂₄ ) values increased in proportion to the dose. Plasma C _5min values were 24.1, 250.0, and 2577.8 ng/mL, and AUC( ₀ _ ₂₄ ) values were 14, 140, and 1390 ng-h/mL for doses of 0.01, 0.1, and 1 mg/kg, respectively. Elimination T _1/2 values were 0.4 hours at 0.01 and 0.1 mg/kg, and 0.5 hours at 1 mg/kg. These results indicate that the pharmacokinetics of API-FB was linear in rats following a single intravenous dose over the dose range of 0.01 to 1 mg/kg. A dose-proportional increase in first-pass kinetics with subcutaneous (PC) administration would indicate non-linear pharmacokinetics in rats following subcutaneous administration.

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Table 1 Pharmacokinetic parameters of API-FB in rats

Dose route Dose (a (mg/kg) ) Tmax (h) Stakh (ng/ml) AUC(0-24) (hh/ml) AUC/dose ( ^10'6 kg h/ml) BA(b) (%) Subcutaneous 0.1 (PC) 0.5±0.0 90.0±12.5 123±9 1234±92 — 1 0.9±0.2 381.3±75.5 804±133 804±133 55.3±8.6 10 0.3±0.0 284.6±58.6 309±70 31±7 — Intravenous (IV) 1 — 2672.3±234.3 (With) 1457±143 — —

-- = not evaluated;

BA = bioavailability

Mean value ± standard deviation (SD) (n=5) (a) Vehicle is a mixture of dimethylacetamide and 5% glucose solution (1:9, v/v) (b) BA = (AUC PC/AUC BB)x (Dose IV / Dose PC)x100 ^{(c) C} 5min

Radioactivity concentrations in the tissues of male albino and pigmented rats were studied after a single intravenous (IV) administration of [ ¹⁴ C]API-MA at a dose of 1.049 mg/kg (1 mg/kg API-FB). The results of this study indicated that the API-MA-related compounds had a broad tissue distribution, with lower concentrations than plasma in most tissues, with the exception of the kidneys and bladder. Radioactivity measured in albino rats was rapidly eliminated from all tissues after intravenous administration of API-MA. API-MA related compounds were also determined to have negligible affinity for melanin in vivo.

Urinary, fecal, bile, and respiratory excretion of administered radioactivity was studied after a single subcutaneous or intravenous administration of [ ¹⁴ C]API-MA at a dose of 1.049 mg/kg (1 mg/kg API-FB) to male Sprague-Dawley rats in two studies.

The first studies examined excretion in urine, feces and bile. Following subcutaneous (SC) or intravenous (IV) administration, API-MA was excreted predominantly in the urine (84.7% and 76.6%, respectively) and to a lesser extent in the bile (15.5% and 20.7%, respectively) and feces (0.2% and 0.3%, respectively) at 24 hours post-dose.

The second study examined excretion in urine, feces and respiration. Following subcutaneous or intravenous administration, API-MA was eliminated predominantly in urine (78.1% and 70.0%, respectively) and feces (20.4% and 28.2%, respectively) at 48 hours post-dose . Respiratory excretion was minimal. The results of this study also show that excretion was almost complete by the time point 48 hours post-dose with subcutaneous or intravenous administration of [ ¹⁴ C]API-MA to rats.

Pharmacokinetics in dogs.

The pharmacokinetics of API-MA was studied in dogs following subcutaneous and intravenous administration. The pharmacokinetic profile of API-MA in dogs is shown in Table 1. 2 below.

Following subcutaneous administration of API-MA to dogs, plasma _Cmax and AUC( _0.24 ) values increased in proportion to dose over _the dose range of 0.1 to 10 mg/kg. Plasma _Cmax values were 86.6, 882.7 _{, and 8842.5 ng/mL, and plasma AUC(0.24 )} values were 252, 2596, and 28626 ng-h/mL for doses of 0.1, 1, and 10 mg/kg, respectively. Plasma _Tmax values ranged from 0.8 to 1.0 hours for the doses tested.

After a bolus intravenous injection of API-MA at a dose of 1 mg/kg, the plasma C _5min value was 4254.4 ng/ml, and the concentration decreased with a triphasic dynamics. The T _1/2 elimination value was 3.0 hours. The AUC( _0.24 ) value was 3093 ng-h/ml _.

The bioavailability of API-MA after subcutaneous administration was good, with calculated values of 81.5%, 84.0%, and 92.7% at doses of 0.1, 1, and 10 mg/kg, respectively.

Based on these results, although subcutaneously administered API-MA underwent minor first-pass kinetics before absorption, API-MA was well absorbed in dogs, and the pharmacokinetics (PK) of API-MA showed a dose-proportional increase over the dose range of 0, 1 to 10 mg/kg.

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Table 2 Pharmacokinetic parameters of API-FB in dogs Path Dose Tmax Stach T1/2(h) AUC (0- AUC / up to VA (b) introduced (a) AND I (h) (ng/ml) a β Υ .24) zu (%) (mg/kg) doses (ng-h/ml (10' ⁶ ) kgh/ml) Sub- 0.1 0.8±0.3 86.6±19ND 1.4±0.2NC 252±34 2518±3 81.5±11 cutaneous .0 39 ,5 (PC) 1 0.8±0.3 882.7±2 ND 1.4±0.3 2.6±0.2 2596±2 2596±2 84.0±8, 51.3 19 19 1 10 1.0±0.0 8842.5± ND 1.5±0.4 2.6±0.1 28626± 2863±1 92.7±7, 1202.1 1814 81 7 Inside 1 4254.4±0.2±0.0 1.1±0.0 3.0±0.1 30093± - — - 543.4 80 venous (With)

(BB) — = not evaluated;

BA = bioavailability;

NC = not calculated;

ND = not detected

Mean value ± standard deviation (SD) (n=4) (a) Vehicle is a mixture of dimethylacetamide and 5% glucose solution (1:9, v/v) (b) BA = (AUC ΠΚ/AUC BB)x (Dose IV / Dose PC)x100 (s) C5 _m j _n

Pharmacokinetics in monkeys.

The pharmacokinetics of API-MA in monkeys was studied after subcutaneous (SC) and intravenous (IV) administration. The pharmacokinetic profile of API-MA in monkeys is shown in Table 1. 3 below.

Following subcutaneous administration to monkeys, _Cmax and AUC( _0.24 ) values increased in proportion to dose over _the dose range of 0.1 to 10 mg/kg. Plasma _Cmax values were 122.6, 1323.4, and 12089.6 ng/mL, and plasma _{AUC(0.24 )} values were 295, 2791, and 31576 ng-h/mL, at doses of 0.1, 1, and 10 mg/kg, respectively. The values of T _max were in the range from 0.3 to 0.4 hours for the studied doses. After reaching _Cmax , the concentrations decreased. After intravenous administration, a multi-exponential decrease was observed with a mean terminal elimination T _1/2 of approximately 2.6 hours, which was close to that obtained after intravenous administration. A steep distribution phase was not apparent after the subcutaneous dose due to the slow absorption of API-MA from the subcutaneous injection site, partially masked by the distribution phase.

After a bolus intravenous administration of API-MA at a dose of 1 mg/kg, the plasma C _5mb value was 5027.0 ng/ml, and the concentration decreased with a triphasic dynamics. The T _1/2 elimination value was 3.2 hours. The AUC( ₀ - ₂ 4) value was 3160 ng-h/ml.

Bioavailability of API-MA when administered subcutaneously was good, with values equal to 94.9%, 90.1% and 101.9% for doses of 0.1, 1.0 and 1.0 mg/kg, respectively.

These results indicate that API-MA was well absorbed in monkeys, and that when administered subcutaneously, API-MA experienced minimal first-pass elimination or showed no first-pass effect before absorption. The pharmacokinetics of API-MA showed a dose-proportional increase in monkeys over the dose range of 0.1 to 10 mg/kg.

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Table 3 Pharmacokinetic parameters of API-FB in dogs Route Dose Tmax Stax T1 / 2 (h) AUC (0-AUC / up to VA (b) entered by (a) ________________________24) zu (h) (ng/ml) α β y (%) AND I (mg/kg) (ng h/ml (10' ⁶ doses ) kgh/ml) Sub- 0.1 0.4±0.1 122.6±2ND 1.6±0.3 NC 295±27 2950±2 94.9±1 dermal 7.3 66 2.4 (PC) 1 0.3±0.0 1323.4±ND 1.4±0.2 2.5±0.2 2791±2 2791±2 90.1±1 316.1 62 62 5.4 10 0.4±0.1 12089.6 ND 1.5±0.3 2.6±0.3 31576± 3157±1 101.9± ±2370.2 1396 40 14.3 Inside 1 - 5027.0±0.3±0.0 1.2±0.1 3.2±0.1 3160±5 NE NE - 786.7 94 venous (s) (BB)

BA = bioavailability;

NC = not calculated;

ND = not detected;

NE = not evaluated

Mean ± Standard Deviation (SD) (n=4) (a) Vehicle is a mixture of dimethylacetamide and 5% glucose solution (1:9, v/v) (b) BA = (AUC PC/AUC BB)x (Dose IV / Dose PC)x100 (C) Csmin

Pharmacokinetics and metabolism of the product.

The following pharmacokinetic (PK) parameters have been summarized for API-MA in plasma and urine, as appropriate, after administration of API-MA:

C _max , maximum observed plasma concentration;

Tmax, time to reach Cmax;

Css, equilibrium plasma concentration;

AUC( _0.24 ), area under the plasma concentration-time curve (AUC) over _a period of 0 to 24 hours;

AUC( _0-inf ), AUC for a period of time from 0 to infinity;

T _1/2 final elimination half-life;

CL/F, apparent clearance (after subcutaneous [SC] dosing);

Fe, dose fraction excreted in urine.

Example 4. Summary of studies.

Pharmacokinetics (PK) of a single dose. Summary.

In Japanese men, systemic exposure to API-MA, measured as C _max and AUC _(0-inf ), increased proportionally to dose over the dose range studied, from 0.001 to 0.5 mg. The mean CL/F ranged from 13.7 to 19.8 l/h. Median T _max for subcutaneous bolus administration of API-MA ranged from 0.375 to 0.750 hours, suggesting rapid systemic absorption of API-MA from the site of subcutaneous dosing. In general, mean T1/2 values increase with increasing dose. This can be explained by API-MA concentrations below the quantitation limit of the assay, which results in an underestimation of T _1/2 and an apparent dose dependence of this parameter after administration of low doses of API-MA. At the highest doses studied, 0.25 and 0.5 mg, mean T _1/2 ranged from 3.77 to 4.27 hours. Mean Fe ranged from 4.24% to 7.10% of the administered dose for doses from 0.004 to 0.5 mg.

Based on pharmacokinetic data from Phase 1 API-MA studies in Caucasian males, AUC( _0.inf ) increased proportionally with dose following a single subcutaneous dose of 0.001 to 0.3, and _a 2-hour subcutaneous infusion of 1, 3, and 6 mg . CL/F values ranged from 18.9 to 27.1 L/h after a single subcutaneous bolus injection and a 2 hour dose infusion of API-MA. The median T _max for subcutaneous bolus administration of API-MA ranged from 0.5 to 0.750 hours, indicating rapid systemic absorption of API-MA from the subcutaneous dosing site, which was not dose-dependent over the range of subcutaneous doses evaluated in this study. At the highest doses studied, 3 and 6 mg, the mean T1 _/2 was approximately 5.2 hours and

- 47 041804 rule increased with increasing dose. Fe had a value in the range from 3.09% to 5.40% of the administered dose for doses from 0.003 to 6 mg.

Multiple dose pharmacokinetics. Summary.

In phase 1 studies of prolonged (continuous for 13 days) subcutaneous infusion (SC INF) of API-MA, Css of API-MA increased in a seemingly dose-proportional manner and mean CL/F values ranged from 17.7 to 20.6 L/h in the analyzed dose range (0.01-1 mg). In studies of hormone-naive Japanese patients with prostate cancer, API-MA was administered at doses of 0.5 or 1.0 mg/day by 2-hour subcutaneous infusion for 14 days. Plasma API-MA concentrations increased and reached _Cmax immediately after completion of the infusion, and then decreased with average T _1/2 values of approximately 3-4 hours on days 1 and 14 at both doses. An approximately dose-proportional increase in exposure was observed with doses of API-MA 0.5 and 1.0 mg/day by subcutaneous infusion. Accumulation of API-MA was not observed after repeated subcutaneous administration for 14 days.

Summary for 1-month depot.

In other studies, patients with prostate cancer receiving GnRH agonist therapy or who are potential future candidates for GnRH agonist therapy received 6, 12, or 24 mg as a single injection of a 1-month depot (N=3 per dosing group). High intensity (high-burst) release of the drug API-MA was observed for several hours after the administration of the depot injection. The AUC( ₀ _ ₂₄ ) value was greater than 60% of the area under the plasma concentration versus time curve from time 0 to the time of the last quantified concentration (AUC( ₀ . _t i _qc )), indicating significant drug release from compositions during the ejection phase. Very low levels of drug concentration were observed over the next few days followed by a slow increase consistent with the expected delayed and slow release from the formulation. In all cases, API-MA was not detected 8 weeks after dosing.

Pharmacokinetics of a single dose of API-MA.

These studies were conducted in Japan as randomized, double-blind, placebo-controlled, parallel-group, ascending-dose studies to evaluate the safety of API-MA, plasma and urinary pharmacokinetics, and endocrine pharmacodynamic (PD) effects following single subcutaneous administration. bolus dose (0.001-0.5 mg) or 2-hour subcutaneous infusion (0.25 and 0.5 mg), which were expected to stimulate testosterone levels. Thirty-seven healthy Japanese men aged 50 to 74 were included in nine cohorts. Subjects included in the first seven cohorts received 0.001, 0.004, 0.01, 0.04, 0.1, 0.25, or 0.5 mg API-MA or placebo as a single subcutaneous bolus. In the 0.001 mg cohort, 3 subjects received API-MA and two received placebo. In the remaining cohorts, 3 subjects received API-MA and one received placebo. Subjects included in the eighth and ninth cohorts received 0.25 or 0.5 mg API-MA or placebo as a single 2 hour subcutaneous infusion. In both cohorts, 3 subjects received API-MA and one received placebo. The plasma pharmacokinetics analysis population consisted of 31 subjects (bolus cohorts: 25; infusion cohorts: 6) and the urinary pharmacokinetics analysis population consisted of 35 subjects (bolus cohorts: 27; infusion cohorts: 8).

To measure the plasma concentrations of API-MA in the subjects of the subcutaneous bolus cohorts, blood samples were taken at the following nominal time points: pre-dose, 0.083, 0.25, 0.5, 0.75, 1, 2, 3, 4, 6, 8, 12, 16, 24, 36, 48 and 72 hours after drug administration. To measure urinary excretion of API-MA, urine samples were taken at the following nominal times: pre-dose, 0 to 4, 4 to 8, 8 to 12, 12 to 24, 24 to 36, 36 to 48 and 48 to 72 hours after drug administration.

To measure plasma concentrations of API-MA in subjects in the subcutaneous infusion cohorts, blood samples were taken at the following nominal time points: before drug administration and after 0.25, 0.5, 1, 2, 2.25, 2.5, 2, 75, 3, 4, 5, 6, 8, 10, 14, 24, 36, 48 and 72 hours after the start of the infusion. To measure API-MA urinary excretion, urine samples were taken at the following nominal times: before administration of the drug and after a period of time from 0 to 4, from 4 to 8, from 8 to 12, from 12 to 24, from 24 to 36, 36 to 48 and 48 to 72 hours after the start of the infusion.

Mean plasma and urine pharmacokinetic parameters for a single dose of API-MA administered as a subcutaneous bolus and for a single dose of API-MA administered as a 2-hour subcutaneous infusion are shown in Table 1. 4 below.

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Table 4 Mean pharmacokinetic parameters for single subcutaneous bolus and single 2-hour subcutaneous infusion

Param Dose (mg)

etr Single subcutaneous bolus Single 2- hourly subcutaneous infusion 0.001 0.004 0.01 0.04 0.1 0.25 0.5 0.25 0.5 plasma A N 2 3 3 3 2 2 3 1 3 Stakh 20.1 61.7 221 966 2415 5895 9050 4020 8230 (pg/ml) (3.3) (9.1) (28) (230) (318) (247) (1429) (NC) (1500) Ttah 0.5 0.5 0.5 0.5 0.375 0.75 0.5 2.25 2.5 (a) (h) (0.5- (0.5- (0.5- (0.25- (0.25- (0.75- (0.5- (2.25- (2.5- 0.5) 0.75) 0.75) 0.5) 0.5) 0.75) 0.75) 2.25) 2.75) AUC(0- 54.1 205 671 2606 5785 18320 29970 13280 34650 inf) (3.7) (33) (49) (868) (1463) (1713) (3950) (NC) (4181) (hpg/m l) Т1/2 (h) 1.59 1.91 1.82 3.35 3.58 4.09 4.27 3.77 4.02 (0.08) (0.25) (0.13) (1.00) (0.88) (0.33) (0.56) (NC) (0.45) CL/F 18.6 19.8 15.0 16.7 17.9 13.7 16.9 18.8 14.6 (l/h) (1.3) (3.3) (1.1) (6.1) (4.5) (1.3) (2.4) (NC) (1.8) Urine N 2 3 3 3 3 3 3 3 3 Fe(%) 0(0) 6.16 5.40 4.24 5.20 7.10 6.33 6.21 5.22 (1.48) (1.16) (1.51) (1.19) (0.46) (0.54) (1.94) (2.04)

NC = not calculated (a) Median (value range)

Following a single subcutaneous bolus of API-MA, systemic exposure to API-MA, measured as C _max and AUC( _0-inf ), increased proportionally to dose over the dose range studied, from 0.001 to 0.5 mg. Dose proportionality was assessed formally by fitting the data with a power-law model. The point exponent estimate was 1.023 for C _max (95% confidence interval [CI], 0.970-1.076) and 1.027 for AUC _(0-inf) (95% CI, 0.979-1.075). Mean values of _Cmax and AUC _(0-inf) after a 2-hour subcutaneous infusion of 0.5 mg of API-MA were close to the mean values after a subcutaneous bolus injection (8230 vs. 9050 pg/ml and 34650 vs. 29970 hpg/ml, respectively). Of note, there was only one subject in the 0.25 mg infusion cohort. Mean CL/F ranged from 13.7 to 19.8 L/h after a single bolus and 2-hour subcutaneous infusion of a dose of API-MA.

Median T _max for subcutaneous bolus administration of API-MA ranged from 0.375 to 0.750 hours, suggesting rapid systemic absorption of API-MA from the site of subcutaneous dosing. Rapid absorption of API-MA appears to be dose-independent.

In general, average T _1/2 values increase with increasing dose. This may be explained by API-MA concentrations below the quantitation limit of the assay, resulting in an underestimation of T _1/2 and an apparent dose dependence of this parameter after administration of low doses of API-MA. At the highest doses studied (0.25 and 0.5 mg), the mean T1/ ₂ ranged from 3.77 to 4.27 hours.

API-MA was not detected in urine after a single subcutaneous bolus injection of 0.001 mg API-MA. In the higher dose bolus and infusion cohorts (0.004 to 0.5 mg), the mean Fe for a single dose ranged from 4.24% to 7.10% of the administered API-MA dose. Plots of cumulative excretion of API-MA in the urine show that the excretion was essentially completed in 24 hours.

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Example 5 Pharmacodynamic effects of API-MA administered as a subcutaneous bolus.

The other studies were phase 1, randomized, double-blind, placebo-controlled, parallel-group, ascending-dose studies to evaluate the safety, tolerability, plasma and urinary pharmacokinetics, and endocrine pharmacodynamic effects of AFIMA administered as a subcutaneous bolus (0.001-0. 3mg) or 2-hour subcutaneous infusion (1-6mg), which are expected to stimulate testosterone. These studies were carried out in France.

Eighty-two healthy Caucasian men aged 50 to 76 years were included in nine cohorts. 81/82 subjects (98.8%) were white and 1/82 subjects (1.2%) were black/African American. Subjects included in the first six cohorts received 0.001, 0.003, 0.01, 0.03, 0.1, or 0.3 mg API-MA or placebo as a single subcutaneous bolus injection. In the 0.3 mg cohort, 6 subjects received API-MA and two received placebo. In the remaining cohorts, 7 subjects received API-MA and three received placebo. Subjects included in the seventh, eighth, and ninth cohorts received 1, 3, or 6 mg of API-MA or placebo by single 2-hour subcutaneous infusion. In these cohorts, 6 subjects received API-MA and two received placebo.

To measure plasma concentrations of API-MA in subjects in the subcutaneous bolus cohorts, blood samples were taken at the following nominal time points: pre-dose and at 0.083, 0.25, 0.5, 0.75, 1, 2, 3, 4, 6, 8, 12, 16, 24, 36, 48 and 72 hours after drug administration. To measure the urinary excretion of API-MA, urine samples were taken at the following nominal times: 12 hours before dosing to the time of dosing, and 0 to 6, 6 to 12, 12 to 24, 24 to 48, and 48 to 72 hours after drug administration.

To measure plasma concentrations of API-MA in subjects in the subcutaneous infusion cohorts, blood samples were taken at the following nominal time points: before drug administration and after 0.5, 1, 1.5, 2, 2.25, 2.5, 3, 4, 6, 8, 10, 14, 18, 26, 50 and 74 hours after the start of the infusion. To measure urinary excretion of API-MA, urine samples were taken at the following nominal times: 12 h before dosing to the time of dosing, and 0 to 6, 6 to 12, 12 to 24, 24 to 48, and 48 to 72 hours after the start of the infusion.

Mean plasma API-MA concentration versus time curves after a single subcutaneous administration of API-MA at doses ranging from 0.001 to 6 mg are shown in FIG. Table 2. Mean percentage coefficients of variation (%CV) of plasma and urine pharmacokinetic parameters for a single dose of API-MA administered as a subcutaneous bolus and for a single dose of API-MA administered as a 2-hour subcutaneous infusion are shown in Table 2 below. 5-8.

Table 5. Mean (%CV) plasma pharmacokinetic parameters after a single subcutaneous administration of API-MA at doses from 0.001 to 0.3 mg Parameter Geometric mean (%CV) (a)

0.001 mg (N=7) 0.003 mg (N=7) 0.01 mg (N=7) 0.03 mg (N=7) 0.1 mg (N=7) 0.3 mg (N=6) Stakh 13.253 42.384 140.140 340.182 1382.196 4349.244 (pg/ml) (19.10) (30.36) (44.26) (17.60) (26.77) (34.08) AUC(0- 47.459 122.246 370.975 1108.096 3943.856 13213.549 inf) (33.78) (16.03) (26.81) (20.49) (14.92) (25.03) (hpg/ml) AUC(0- 26.693 100.915 345.193 1069.885 3887.968 13155.656 tlqc) (21.64) (20.18) (28.87) (20.65) (14.81) (25.06) (hpg/ml) Т1/2 (h) 1.796 1.425 2.172 2.610 3.079 3.451 (b) (1.20- (1.18- (1.82- (1.50- (2.29- (2.98- 4.58) 2.34) 2.72) 3.11) 3.56) 4.10) Tmax (h) 0.500 0.750 0.500 0.500 0.500 0.625 (b) (0.25- (0.50- (0.25- (0.25- (0.25- (0.25- 1.00) 1.00) 0.75) 0.75) 0.75) 0.75) CL/F (l/h) 21.071 24.541 26.956 27.073 25.356 22.704 (33.78) (16.03) (26.81) (20.49) (14.92) (25.03) Vz/F (l) 63.925 55.862 85.629 95.981 108.017 114.225 (27.13) (34.30) (34.48) (14.77) (21.08) (32.60)

Vz/F = apparent volume of distribution (a) CV(%) = 100xV(exp(SDlog2)-1) where SDlog is the standard deviation of log-transformed values

- 50 041804 (b) Median values (minimum-maximum)

Table 6 Mean (%CV) Plasma Pharmacokinetic Parameters Following a 2-Hour Infusion of API-MA at Doses of 1 to 6 mg

Parameter Geometric mean (%CV) (а)

1 mg (N=6) 3 mg (N=6) 6μγ(N=6) Stax (pg/ml) 13050.559 (20.79) 39402.798 (14.80) 82477.820 (22.63) AUC(O-inf) 43825.188 (25.51) 141488.720(11.42) 317753.435 (25.60) (h-pg/ml) AUC(O-tlqc) 43656.011 (25.51) 141392.642 (11.41) 317666.507 (25.60) (h pg/ml) T1/2(h) (b) 3.643 (3.46-3.83) 5.249 (3.19-5.86) 5.264 (4.56-5.62) Tmax (h) (b) 2.250 (2.00-2.25) 2.250 (2.25-2.50) 2.250 (2.00-2.50) CL/F (l/h) 22.818(25.51) 21.203(11.42) 18.883 (25.60) Vz/F (l) 119.955 (27.97) 149.910(28.78) 140.984 (28.67)

Vz/F = apparent volume of distribution (a) CV(%) = 100xV(exp(SDlog2)-1) where SDlog is the standard deviation of log-transformed values (b) Median values (minimum-maximum)

Table 7. Mean (%CV) urine pharmacokinetic parameters after a single subcutaneous administration of API-MA at doses from 0.001 to 0.3 mg

Parameter Geometric mean (%CV)

0.001 mg (N=7) (а) 0.003 mg (N=7) 0.01 mg (N=7) 0.03 mg (N=7) 0.1 mg (N=7) 0.3 mg (N=6) CLr (l/h) 1048.546 1180.964 1073.430 937.560 1048.697 860.937 (15.74) (21.35) (30.52) (24.89) (41.44) Ae(O-t) 34.658 119.177 370.540 1003.082 4077.298 11326.187 (ng) (17.70) (20.69) (31.55) (28.29) (30.17) Fe(%) 3.466 3.973 3.705 3.344 4.077 3.775 (17.70) (20.69) (31.56) (28.29) (30.17)

(a) Only 1 subject above the lower limit of quantification (LLOQ), 6 subjects assumed values of 0

Ae(0-t) = amount of drug excreted in urine from time 0 to time t

CLr = hepatic clearance

Table 8 Mean (%CV) urine pharmacokinetic parameters after

2-hour infusion of API-MA at doses of 1 to 6 mg

Parameter Geometric mean (%CV) 1 mg (N=6) Zmg (N=6) 6μγ(N=6) CLr (l/h) 686.544 (29.02) 835.762 (45.31) 1016.230 (27.70) Ae(O-t) (ng) 29971.789 (27.97) 118170.544 (41.46) 322822.342 (10.34) Fe(%) 2.997 (27.97) 3.939 (41.46) 5.380(10.34)

Ae(0-t) = amount of drug excreted in urine from time 0 to time t

CLr = hepatic clearance

The peak concentration of API-MA (C _max ) increased in proportion to the dose after the introduction of single subcutaneous bolus doses in the range from 0.001 to 0.3 mg. Systemic exposure to API-MA, measured as AUC( _0.mf ), increased in proportion to dose following single subcutaneous doses of 0.001 to 0.3 and 2-hour subcutaneous infusions _of 1, 3, and 6 mg. The calculated exponents for the power equation were 1.003 for C _max (95% Cl, 0.956-1.050) and 1.019 for AUC _{(0.mf )} (95% Cl, 0.997-1.040). CL/F values ranged from 18.9 to 27.1 L/h after a single subcutaneous bolus and a 2-hour dose infusion of API-MA.

Median T _max for subcutaneous bolus administration of API-MA ranged from 0.5 to 0.750 hours, indicating rapid systemic absorption of API-MA from the site of subcutaneous dosing. Rapid absorption of API-MA when administered subcutaneously was not dose-dependent over the subcutaneous dose range analyzed in this study.

In general, average T _1/2 values increase with increasing dose. Analysis of FIG. 2 suggests that the probable cause of the longer T _1/2 could potentially be the sensitivity of the assay and the inclusion of measurable API-MA concentrations at the end of the curve when estimating T _1/2 for higher doses. Therefore, the observed dose dependence of this parameter is not evidence of non-linear pharmacokinetics of API-MA. At the highest doses studied, 3 and 6 mg, the mean T _1/2 is approximately 5.2 hours.

Only a small amount of API-MA was detected in the urine after a single subcutaneous bolus of 0.001 mg of API-MA. The mean (CV%) Fe for this cohort was 3.466%. For other cohorts of bolus and infusion doses (0.003 to 6 mg), the mean single dose Fe ranged from 2.997% to 5.380% of the administered dose of API-MA.

Example 6 Pharmacokinetics of multiple doses of API-MA.

Other studies were phase 1 clinical studies of repeated administration of API-MA. These studies were carried out in France. They were randomized, double-blind, placebo-controlled, parallel-group, ascending-dose studies of safety, tolerability, plasma pharmacokinetics, and endocrine pharmacodynamic effects of API-MA administered as a subcutaneous bolus (0.1 mg) on day 1 s. followed by continuous subcutaneous infusion (i.e. 24 h/day) from day 2 to day 14 (0.01, 0.1, 0.3, or 1.0 mg/day) which was expected to suppress testosterone. Thirty healthy Caucasian men aged 50 to 78 were included in four cohorts; 29/30 subjects (96.7%) were white and one subject (3.3%) was black.

To measure API-MA plasma concentrations after subcutaneous bolus administration, blood samples were taken at the following nominal time points: before drug administration and after 0.083, 0.25, 0.5, 0.75, 1, 2, 4, 6, 12 , 16 and 24 hours after drug administration. During the subcutaneous infusion, blood samples were taken at the following nominal times: 6, 12, 24, 54, 60, 72, 150, 156, 168, 222, 228, 240, 294, 300 and 312 hours after the start of the infusion.

Mean plasma pharmacokinetic parameters for a single dose of API-MA administered by subcutaneous bolus injection are shown in Table 1. 9 by dose group for comparison with values after a continuous 13-day subcutaneous infusion on days 2-14, as shown in table. 7. Since the pharmacokinetics of a single dose of API-MA could only be assessed up to 24 hours prior to the infusion of API-MA, only C _max , T _max , and AUC ( _0-24 ) could be determined from the pharmacokinetic parameters. Interindividual variability in pharmacokinetic parameters was generally low, with %CV <58%.

Table 9. Mean (%CV) pharmacokinetic parameters by dose group after a single subcutaneous bolus injection (0.1 mg) on day 1

Geometric mean (%CV)

Parameter 0.01 mg/day 0.1 mg/day 0.3 mg/day 1.0 mg/day

N 6 6 6 5

Stakh (pg/ml) 1870(27) 1590(31) 1650(26) 1290(58)

Tmax (H) (a) 0.500 0.500 0.500 0.500 (0.500, 0.750) (0.250, 1.000) (0.250, 1.033) (0.250, 0.750)

AUC(O-tlqc) (hpg/mL)5080(22) 4280(12) 4680(27) 4050(29)

Note: All groups received a subcutaneous bolus injection (0.1 mg) on day 1; dose group indicates which randomized dose subjects received by subcutaneous infusion from day 2 to day 14 (0.01-1.0 mg/day) (a) Median (range) (b) AUC( _0-tlq c), in in this case, equal to AUC( _0-24 )

Mean plasma pharmacokinetic parameters for API-MA administered by continuous 13-day subcutaneous infusion on days 2-14 are shown in Table 1. 7. C _ss increased in a seemingly dose-proportional manner over the dose range studied, from 0.01 to 1.0 mg. For all cohorts, CL/F ranges from 17.7 to 20.6 L/h. Interindividual variability in pharmacokinetic parameters was low, with CV% <40%.

Table 10. (%CV) Pharmacokinetic Parameters During a Continuous 13-Day Subcutaneous Infusion of API-MA (Days 2-14)

Geometric mean (%CV)

Parameter 0.01 mg/day 0.1 mg/day 0.3 mg/day 1.0 mg/day N 6 6 6 5 Css (pg/ml) 20.2 (34) 226 (17) 708 (19) 2280(16) CL/F (l/h) 20.6 (40) 18.5 (18) 17.7 (18) 18.3(16)

C _ss = defined as AUC (day 2-day 14)/actual time elapsed since collection

- 52 041804 samples on day 2, 6 hours, until the time of sampling on day 14, 24 hours.

The other studies were phase 1 clinical studies with multiple doses of API-MA. They were conducted as open-label studies with ascending doses of API-MA given by 2-hour subcutaneous infusion once a day for 14 days, which was expected to suppress testosterone in hormone-naive Japanese prostate cancer patients. Six patients received API-MA at doses of 0.5 mg (3 patients) and 1.0 mg (3 patients) per day for 14 days.

To measure plasma API-MA concentrations, blood samples were taken at the following time points: day 1 (pre-dose and 2, 4, 6, 10 hours post-dose); days 2, 4, 6, 8, 10 and 12 (prior to dosing); day 14 (before dosing and 2, 4, 6, 10, 24, 48 hours after drug administration); day 21; and day 28. To measure the urinary excretion of API-MA, urine samples were taken at the following time points: day 1 (before dosing and at times 0 to 4, 4 to 8, 8 to 12, 12 to 24 hours post-dose) and day 14 (0 to 4, 4 to 8, 8 to 12, 12 to 24 hours post-dose).

Time profiles of mean [±SD] API-FB plasma concentrations for repeated subcutaneous administration of API-MA at 0.5 and 1.0 mg/day for 14 days are depicted in FIG. 3. Summary data of pharmacokinetic parameters on day 1 and day 14 at two doses are presented in table. 11 below. The Cmax and AUC values on days 1 and 14 were similar, demonstrating the absence of peptide accumulation. C _max and AUC were proportional to the dose.

Table 11 Summary of Mean (±SD) Pharmacokinetic Parameters on Days 1 and 14

0.5 1.0 Day 1 Day 14 Day 1 Day 14 N 3 3 3 3 Tmax (h) 2.11 (0.0344) 2.08 (0.0165) 2.11 (0.0510) 2.11 (0.0587) Stax (pg/ml) 8120 (1420) 8130 (1710) 16000 (1210) 15500 (503) λζ (1/h) 0.200 (0.0160) 0.198 (0.00349) 0.221 (0.0187) 0.205 (0.0103) Τ1/2 (h) 3.48 (0.290) 3.50 (0.0614) 3.15 (0.260) 3.38 (0.164) AUC(O-tau) 36500 (7740) 39100 (8050) 70200 (5840) 71200 (5650) (h pg/ml) CL/F (l/h) 13.4 (3.27) 12.6 (2.86) 13.6 (1.10) 13.4 (1.10) Vz/F (l) 66.9 (13.3) 63.5 (13.2) 61.6 (6.32) 65.7 (7.83) AUC(O-inf) (h pg/ml) 36800 (7860) ΝΑ 70600 (5990) ΝΑ MRT (h) 4.78 (0.522) ΝΑ 4.64 (0.405) ΝΑ AI(AUC) ΝΑ 1.07 (0.0659) ΝΑ 1.01 (0.112) A1(T1/2) ΝΑ 1.01 (0.0678) ΝΑ 1.07 (0.0429) R(AUC) ΝΑ 1.07 (0.0676) ΝΑ 1.02 (0.111) R(Cmax) ΝΑ 1.00 (0.0916) ΝΑ 0.967 (0.0502)

All parameters and summary data are given to three significant figures. λz=apparent elimination rate constant, Al=accumulation index, AUC(0-tau)=area under the plasma concentration versus time curve from 0 to time τ (tau) (24 h), MRT=mean residence time per time period 0 to infinity, NA-n/a, R=accumulation rate, Vz/F=apparent volume of distribution.

Note: R(AUC) is calculated as AUC(0-tau) (day 14)/AUC(0-tau) (day 1).

Note: Al(AUC) is calculated as AUC(0-tau) (day 14)/AUC(0-inf) (day 1).

After subcutaneous administration of API-MA at a dose of 0.5 mg/day, as well as 1.0 mg/day, for 14 days, Cmax was determined immediately after completion of the 2-hour infusion on days 1 and 14, and then decreased, with an average T _1/2 is approximately 3 to 4 hours on both days 1 and 14 at both doses. At 0.5 mg/day, mean CL/F values were 13.4 and 12.6 L/h on days 1 and 14, respectively, and at 1.0 mg/day, 13.6 and 13.4 L/h. h on days 1 and 14, respectively, indicating that the apparent clearance of API-FB was nearly the same for both doses. The Vz/F values for API-FB were also similar at both dose levels. Estimated accumulation index (AI), defined as the ratio of AUC( _0-tau ) after multiple dosing/AUC( _0-int ) after a single dose, and R, defined as the ratio of AUC( _0-tau ) after multiple dosing/AUC( _{0 -tau} ) after a single dose were both close to 1, indicating time-independent pharmacokinetics of API-FB, with minimal or no drug accumulation following a 2-hour subcutaneous infusion of 0.5 and 1 mg doses daily for 14 days.

Following subcutaneous administration of API-MA at 0.5 or 1.0 mg/day for 14 days, urinary excretion of API-FB was nearly complete 8 hours after dosing on days 1 and 14. Mean percent cumulative excretion 24 hours after dosing was 6.50% on day 1 and 8.99% on day 14 for the 0.5 mg/day dose, 8.86% on day 1 and 9.41% on day 14 for dose 1 .0 mg/day respectively. These results suggest that renal excretion does not significantly contribute to API-FB clearance.

Example 7. Pharmacokinetics of 1-month API-MA depot.

Other studies included patients with prostate cancer who had completed primary prostate cancer treatment at least 6 months prior to screening and were either receiving GnRH therapy or were potential candidates for future GnRH therapy. Nine patients were enrolled, three in each dose group (6, 12 and 24 mg). All were white men. Patients received API-MA as a single 1-month subcutaneous depot injection in the abdomen, which was supposed to initiate both high-intensity release of API-MA and rapid stimulation of the hypothalamic-pituitary-gonadal axis and, as expected, to suppress testosterone. In total, 4 out of 9 patients received concomitant GnRH therapy. To measure plasma API-MA concentrations, blood samples were taken pre-dose and at the following nominal time points after 1-month depot injection: Month 1 (0.25, 0.5, 0.75, 1, 2, 4, 6 and 12 noon, and days 2, 3, 5, 8, 15, 22 and 29), month 2 (days 8, 15, 22 and 29), and month 3.

Fig. 4 and 5 show mean plasma concentration versus time curves by dose group for day 1 (up to 12 noon) and full profile (up to month 3). The high rate of release of drug concentrations for API-MA was observed several hours after the administration of the depot injection. The value of AUC( _0-24 ) is more than 60% of the observed AUC(o-ti _qc ), showing a significant release of the drug from the composition in the ejection phase. Drug concentrations were very low over the next few days followed by a slow rise suggesting a delayed and slow release from the formulation and onset of desensitization after continuous administration of API-MA. In all cases, AFIMA was not detected 8 weeks after dosing.

In table. 12 shows descriptive statistics by dosage group, including pharmacokinetic parameters C _max , T _max , AUC( _0-24 ), plasma concentration-time area under the curve from day 0 to day 29 of month 1 (AUC( _0-29d )), AUC( _0-tlqc ) and time to last quantifiable concentration (Tlqc). Mean values representing drug exposure generally increase slightly subproportionately with dose.

Table 12 Summary of Pharmacokinetic Parameters after Depot Injection Geometric Mean (%CV)

Parameter 6 mg/month (N=3) 12 mg/month (N=3) 24 mg/month (N=3) Stax (pg/ml) 16541.7(45.3) 14408.6(41.7) 25518.0(17.5) Tmax (h) (a) 2.000(1.03, 2.12) 2.050(1.02, 4.07) 2.050 (2.00, 4.00) AUC(0-24) 3316.6(28.7) 4979.1 (23.4) 7466.3(31.9) (denpg/ml) AUC(0-29d) 4328.8(33.1) 5753.2 (30.9) 8701.2 (42.1) (day pg/ml) AUC(O-tlqc) 4947.6 (39.0) 6582.9 (43.7) 9948.6 (54.4) (day pg/ml) Tlqc (h) 42.9 (16.2) 41.5 (44.6) 47.2 (21.1)

(a) Median (range of values)

In general, the low plasma concentrations of API-MA, the delayed release profile over 1 month after administration, and the high inter-patient variability of the 1-month depot formulation were considered unsuitable for further clinical development in patients with prostate cancer. In addition, these results are not applicable to the dosing strategy to be used for patients with hypothalamic hypogonadism, since (for them) stimulation of the hypothalamic-pituitary-gonadal axis without testosterone suppression is desirable.

Pharmacodynamics Single Dose Pharmacodynamics Summary.

After administration of a single dose of API-MA to 37 Japanese men, an increase in serum LH and FSH concentrations was observed. LH and FSH concentrations peaked between 12 and 24 hours and returned to baseline after 72 hours. The magnitudes of the increase in hormone concentrations were similar over the entire dose range, from 0.001 to 0.5 mg. In a single-dose phase 1 study of AFIMA in 82 Caucasian men, administration of AFI-MA resulted in elevated serum LH and FSH concentrations that peaked between 6 and 12 hours and returned to baseline by 72 hours. The magnitude and duration of increases in hormone levels were similar over the entire dose range, from 0.001 to 6 mg.

Summary of multiple dose pharmacodynamics.

In the two multiple dose studies, all doses used resulted in a gradual suppression of LH levels, as expected. In studies C18001, 30 healthy Caucasian males received a single subcutaneous injection of 0.1 mg followed by a prolonged (continuous for 13 days) subcutaneous infusion of API-MA at doses of 0.01, 0.1, 0.3, and 1.0 mg. /day. Gonadotropin concentrations peaked 24 hours after the 0.1 mg bolus on Day 1, consistent with other phase 1 single dose studies. During prolonged infusion of API-MA, serum LH and FSH concentrations decreased to below baseline values and returned to baseline values 7 days post-dose. For most subjects, serum LH concentrations dropped to low levels. All subjects in the 0.1 and 0.3 mg/day cohorts had LH concentrations below the lower limit of normal for a significant portion of the subcutaneous infusion period. API-MA reduces serum levels of LH and FSH after a transient increase, and this inhibition is maintained throughout administration. Serum PSA (prostate specific antigen) levels decreased after administration of API-MA, more pronounced in patients treated with API-MA 1.0 mg/day.

Pharmacodynamic effects of a single dose of API-MA.

In the phase 1 API-MA clinical trials, subjects included in the first seven cohorts received a single subcutaneous bolus injection at doses of 0.001, 0.004, 0.01, 0.04, 0.1, 0.25, or 0.5 mg of API- MA or placebo. Subjects included in the eighth and ninth cohorts received a single subcutaneous infusion with doses of 0.25 or 0.5 mg API-MA or placebo. The pharmacodynamics of the following hormones were assessed: LH, FSH, dehydroepiandrosterone sulfate (DHEA-S), growth hormone (GH), prolactin (PRL), thyroid stimulating hormone (TSH), and adrenocorticotropic hormone (ACTH). The pharmacodynamic analysis population consisted of 37 subjects (bolus cohorts: 29; infusion cohorts: 8). To measure serum hormone concentrations in subjects in both the bolus and infusion cohorts, blood samples were taken at the following nominal time points: pre-dose and 2, 4, 6, 8, 12, 24, 48, 72, and 312 hours post-dose. drug administration. In addition, blood samples were taken for measurement of LH and FSH on the day before the dose of API-MA. Time dependences of mean serum LH concentrations after a single subcutaneous bolus of API-MA at doses ranging from 0.001 mg to 0.5 mg are shown in FIG. 6. LH concentrations peaked between 12 and 24 hours and usually returned to baseline 72 hours after drug administration. The magnitude and duration of the increase in LH concentration were similar for the entire range of doses, from 0.001 to 0.5 mg. Time dependences of LH were similar after a single 2-hour subcutaneous infusion of API-MA (data not shown).

As shown in FIG. 7, serum FSH concentrations increased after a single subcutaneous bolus dose of API-MA compared with placebo. FSH elevations peaked within 24 hours and typically returned to pre-drug levels 72 hours post-injection. The magnitude and duration of increases in LH and FSH concentrations were similar over the entire dose range, from 0.001 to 0.5 mg. Time dependences for LH and FSH were similar after a single 2-hour subcutaneous infusion of API-MA (data not shown).

The other studies were phase 1 single dose AFIMA clinical studies in healthy men aged 50 to 76 years. Subjects included in the first seven cohorts received 0.001, 0.003, 0.01, 0.03, 0.1, or 0.3 mg API-MA or placebo as a single subcutaneous bolus injection. Subjects included in the seventh, eighth, and ninth cohorts received 1, 3, or 6 mg of AFIMA or placebo by single 2-hour subcutaneous infusion. The pharmacodynamics of each of the following hormones were assessed: LH and FSH concentrations, PRL (prolactin), TSH (thyroid stimulating hormone), cortisol, sex hormone binding globulin (SHBG), and plasma ACTH (adrenocorticotropic hormone) (also known as corticotropin) were measured per day before the dose and on day 4, at the last visit to the doctor (Final Visit). To measure serum LH and FSH concentrations in bolus cohorts, blood samples were taken at the following nominal time points: the day before dosing, before dosing, and after 0.083, 0.25, 0.75, 1, 2, 3, 4 , 6, 8, 12, 16, 24, 36, 48 and 72 hours after drug administration. In infusion cohorts, blood samples were taken at the following nominal times: the day before dosing, before dosing or infusion, and at 0.5, 1, 1.5, 2 (end of infusion), 2.25, 2, 5, 3, 4, 6, 8, 10, 14, 18, 26, 50 and 74 hours after the start of the infusion. Serum LH concentrations versus time are shown in FIG. 8. Serum LH concentrations increased after a single subcutaneous bolus injection of API-MA, as well as after a single 2-hour subcutaneous infusion of API-MA. Concentrations peaked between 6 and 12 hours and returned to baseline after 72 hours. The magnitude and duration of LH elevations were similar over the entire dose range, from 0.001 to 6 mg.

Administration of API-MA generally resulted in an initial modest increase in mean FSH concentrations at all dose levels, followed by a decline to baseline levels after 72 hours, as shown in FIG. 9. This increase was not dose dependent. Peak values were generally reached after approximately 12 hours for all dose levels. No relevant changes were observed

- 55 041804 serum concentrations for SHBG, prolactin, TSH, corticotropin or cortisol after administration

API-MA at any dose level.

Example 8 Pharmacodynamic effects of repeated administration of API-MA.

These studies were Phase 1 studies of multiple-day continuous subcutaneous infusion of API-MA in 30 healthy Caucasian men over 50 years of age. Subjects included in four cohorts received a single subcutaneous bolus injection of API-MA 0.1 mg or placebo (Day 1) followed by 0.01, 0.1, 0.3, or 1.0 mg/day of API-MA or placebo by continuous subcutaneous infusion for 13 days (days 2-14). Five to six men received active API-MA and 1-2 men received placebo in each dose level cohort. The pharmacodynamics of the following hormones were evaluated: LH and FSH.

To measure serum LH and FSH concentrations, blood samples were taken on the day before the API-MA dose at the following nominal times: -24, -16, and -12 hours (before) the subcutaneous bolus dose, immediately before the subcutaneous bolus administration, and 6, 12, 24, 30, 36, 48, 78, 84, 96, 174, 180, 192, 246, 252, 264, 318, 324, and 336 hours after the bolus dose. The subcutaneous infusion was started 24 hours after the bolus injection; all samples taken after the 24 hour time point were taken at the time of the subcutaneous infusion. Blood samples were also taken on days 16, 17, 21, 28 and 44 to monitor the return of hormone concentrations to baseline values.

As shown in FIG. 10 and 11, in all active treatment groups, mean serum LH and FSH concentrations increased after a 0.1 mg subcutaneous bolus injection of API-MA on day 1. During the 13-day subcutaneous infusion of API-MA, mean concentrations of LH and FSH in serum decreased to below baseline values and almost returned to baseline values within 7 days after dosing. For most subjects, serum LH concentrations decreased to low values. All subjects in the 0.1 and 0.3 mg/day cohorts had LH concentrations below the lower limit of normal for most of the subcutaneous infusion period. Conversely, mean serum LH and FSH concentrations remained within the normal range throughout the studies in subjects in the placebo group.

The studies were phase 1 studies with hormone-naive Japanese patients with prostate cancer. Six patients received doses of API-MA 0.5 mg (3 patients) and 1.0 mg (3 patients), which were administered by 2-hour subcutaneous infusion once a day for 14 days. Summary statistics of LH, FSH, GH (growth hormone), PRL (prolactin), and TSH (thyroid stimulating hormone) serum concentrations, as well as ACTH plasma concentration and serum prostate specific antigen (PSA) concentration, at baseline and at each point estimates, deviations from baseline were calculated for each dose, and plots of data (individual values and mean ± standard deviation) versus time were plotted for each dose. Serum LH profiles are shown in Fig. 12 for API-MA 0.5 mg/day dosing group. Serum LH levels rose sharply on day 2, and returned to baseline by day 4. These levels were completely suppressed from day 6 to day 16, and returned to baseline one week after the last dose. Serum LH changes were similar for 0.5 and 1.0 mg API-MA (data not shown for API-MA 1.0 mg/day dose group).

Serum FSH profiles are shown in Fig. 13 for API-MA 0.5 mg/day dosing group. Serum FSH levels also rose sharply on day 2, and returned to baseline by day 4. These levels were completely suppressed from day 6 to day 16, and returned to baseline one week after the last dose. Serum FSH changes were similar for 0.5 and 1.0 mg API-MA (data not shown for API-MA 1.0 mg/day dose group).

Serum PSA levels decreased after administration of API-MA and low PSA levels persisted for a week after the last dose in all subjects. Serum PSA levels decreased by approximately 40% from baseline in patients treated with 0.5 mg API-MA, and a greater decrease of approximately 50-60% was seen in patients treated with 1.0 mg API-MA. MA.

Example 9 Effects of 1-month depot of API-MA.

Nine patients with prostate cancer participated in other studies, three in each dose group (6, 12, and 24 mg). Patients received API-MA as a single 1-month depot injection, which was designed to initiate a high-intensity release of API-MA and rapidly stimulate the hypothalamic-pituitary-gonadal axis. A total of 4 of 9 patients received concomitant GnRH therapy. Pharmacodynamic evaluation included serum LH concentrations and serum PSA concentrations. Results were grouped for patients who received or did not receive concomitant GnRH therapy.

Decreases in LH consistent with changes in testosterone have been observed in GnRH-naive patients. Post-screening serum LH concentrations ranged from 0.1 to 0.5 mIU/mL in the 6 mg dosing group, <0.1 to 7.9 mIU/mL in the 12 mg dosing group, and from 0.3 to 9.8 mIU/mL in the 24 mg dosing group, with inter-patient variation throughout the follow-up period. Two of nine patients receiving GnRH analog concomitant therapy (one in the 6 mg dosing group and one in the 12 mg dosing group) had PSA concentrations <0.01 ng/mL with undetectable relative deviations from baseline for all measurements, except for one, throughout the study. In the remaining seven patients, the largest relative decrease in PSA from baseline was observed on day 29 of month 1, (8% and 19% for patients in the 6 mg dosing group, 25% and 62% for patients in the 12 mg dosing group, and 74 %, 79% and 88% for patients in the 24 mg dosing group). A further decrease from baseline was observed in three patients (one in the 6 mg dosing group, one in the 12 mg group, and one in the 24 mg group) on day 29 of month 2, with the largest reduction in PSA of 91% observed in a patient in the 24 mg dosing group.

Example 10 Use of Compound 1 and Relugolix in ART.

In order to improve the safety and efficacy of the outcomes of ART, such as IVF, and/or in the PE process, this document identifies key modifications to some of the main steps in this process, including the use of compound 1 and relugolix.

Traditional IVF protocols begin with an initial phase known as the COS. In this phase, on day 2 or 3 of the patient's menses, FSH is administered to promote follicular growth and development, and continued until ovulation occurs (ca. day 14). Approximately 3-5 days after the start of FSH administration, a GnRH agonist or, now more commonly, a GnRH antagonist, is added to the regimen to prevent premature ovulation (release of immature follicles due to LH surge) and, likewise, continue FSH until ovulation occurs. The common GnRH antagonist currently used in these protocols is cetrorelix injections, but in this particular application, the oral GnRH antagonist relugolix is used because it reduces the number of multiple injections in ART, such as IVF, and/or during PE, and may allow more tailored titration of GnRH antagonist activity compared to drug injections. Improving the residual activity of the GnRH antagonist can improve the LH response to the trigger (compound 1, described below), which ultimately improves the frequency of implantation. Relugolix may inhibit and prevent premature ovulation by allowing eggs to mature and be retrieved from the ovaries (rather than the fallopian tubes). Relugolix may also prevent high-grade multiple pregnancy, which can result from the contact of eggs with sperm in the fallopian tube during intercourse. Together, this stimulation process with FSH and the GnRH antagonist relugolix is called COS.

After the follicles have reached a predetermined state in which the dominant follicle has a measurable size of >14 mm, a so-called trigger agent is used to promote final maturation, release and retrieval of eggs from the ovary in preparation for IVF and ET into the uterus. Compound 1 (2-(N-acetylD-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-Lleucyl-Ksh-methyl-G-arginyl is used as a trigger agent -g-tryptophanamide, or a pharmaceutically acceptable salt, and a pharmaceutically acceptable excipient). Compound 1 is used as a trigger to promote oocyte maturation and induce ovulation for subsequent retrieval, in vitro fertilization and PE. Other agents (eg, estradiol and progestins) are also used to support the uterus (endometrium), the so-called luteal phase support in preparation for implantation.

One of the main risks associated with ART, including IVF and/or the ET process, is the development of OHSS. Although some patients are at increased risk of developing OHSS, the use of hCG-based trigger agents (i.e., hCG alone or hCG with a GnRH agonist) is known to increase the risk of OHSS. Compound 1 is expected to significantly reduce the risk of OHSS.

When compound 1 is used as a trigger agent, it is expected to provide a similar or improved pregnancy rate compared to hCG-based trigger agent or GnRH agonists. Compound 1 promotes the maturation, release (ovulation) and cure of fresh mature oocytes (eggs) from the ovaries, resulting in a higher pregnancy rate while significantly reducing the risk of key side effects such as OHSS.

The use of hCG-based trigger agents is known to increase the need for segmentation of freezing protocols, delaying embryo transfer. Due to the mechanism of action (MOA) of compound 1, it has less negative effect on the endometrium compared to current treatments. Thus, the endometrium is ready for implantation (higher endometrial receptivity) immediately after egg retrieval, thereby reducing the need for segmentation (freezing the egg or embryo between retrieval and implantation). After retrieval, the egg is fertilized with sperm, and the unfrozen embryo is implanted into the endometrium with the onset of pregnancy. Compound 1 results in less need for a segmented protocol with cryopreservation, thereby reducing the number of IVF cycles and reducing the time to pregnancy, while maintaining an acceptable pregnancy rate, with a significantly lower incidence of OHSS.

- 57 041804

Example 11 Investigation of the physiological effects of compound 1 in women.

Part 1. Identification of the dose range of Compound 1.

Kisspeptin-54 has previously been shown to be clinically effective as a trigger for oocyte maturation in IVF studies. Doses of Compound 1 administered in the early follicular phase of the menstrual cycle were analyzed in this study to allow the identification of doses capable of stimulating an LH response and comparison of similarities and differences with the LH response of kisspeptin-54.

The study population included healthy women, aged 18-35 years, with a BMI of 18-30 kg/m ² , with no medical problems and not taking any medications or hormonal contraception. Three healthy women were selected and randomized to receive a single dose of each of the three study regimens described below (one regimen per study period). All women were scheduled for three visits to the doctor on day 1 (D1) of the studies (each during the follicular phase of the menstrual cycle). Each subject received a single dose of one of the following three study regimens at the study day 1 visit in each study period (three study periods in total), such that by the end of that study period each subject received all three of the following study treatment regimens (one per study period). research):

Kisspeptin-54 (KP54), 9.6 nmol/kg;

compound 1, 0.003 nmol/kg* or 0.00368 µg/kg;

compound 1, 0.03 nmol/kg* or 0.0368 µg/kg.

* For example, a 60 kg woman who is dosed with Compound 1 at 0.003 nmol/kg will receive 0.18 nmol or 0.221 µg. The order in which any subject received one of the three study regimens was determined by a randomization matrix.

Vials of compound 1 were stored at 4°C and contained 200 μg (0.2 mg) in 2000 μl (2 ml), i.e. 0.1 µg/µl (0.1 mg/ml). Lyophilized kisspeptin-54 (600 nmol per vial) was reconstituted in 0.5-1 ml normal saline in preparation for subcutaneous injection (Table 13).

Table 13 Compound 1 Subcutaneous Composition

Component Function Quantity per vial (2 ml) Compound 1 drug substance API (active pharmaceutical ingredient) 0.21 mg (0.2 mg) Connection 1 - free base D-Mannitol, JP/USP/Ph.Eur. Tonicity regulator 100 mg Ice vinegar acid, JP/USP/Ph.Eur. pH regulator Required amount Water for injection, JP/USP/Ph.Eur. Solvent q.s. (required amount) up to 2 ml

The studies included attending a screening exam to complete the participants' complete medical records and to perform a general physical and blood test. The three study periods each consisted of three scheduled follow-up visits during the study period (excluding screening and follow-up). The study day 1 visit (TD1-study day 1) of each study period occurred during the follicular phase of the menstrual cycle (days 1-4), and the TD2 and TD3 visits occurred 24 and 48 hours after drug administration, respectively (Figure 14). . Follow-up telephone calls were made 7-10 days after drug administration in each study period.

On study day 1, after obtaining a negative urine test confirming the absence of pregnancy, a single dose (by subcutaneous injection in the abdomen) of compound 1 (0.003 nmol/kg or 0.03 nmol/kg) or kisspeptin was administered at time zero (0) -54 (9.6 nmol/kg).

Serum levels of LH, FSH, E2 (estradiol), P (progesterone), and SHBG were determined immediately after dosing at 30-minute intervals over 14 hours (FIGS. 15A-15C, 16A-16C, 17, 18, 19, 20A and 20V). These pharmacodynamic parameters (PD variables) were also assessed 24 (day 2 studies) and 48 hours (day 3 studies) after drug administration. SHBG changed more slowly and was measured every 3 hours to reduce blood volume.

- 58 041804

To measure the levels of sex hormones (LH, FSH, E2 and P) in serum, up to 3 ml of blood volume is required. Blood samples for serum analysis are collected in plain Vacutainer tubes (Beckton Dickson,

Franklin Lakes, NJ, USA) and centrifuged after clotting (ca. 1 h at room temperature) for 10 min at 3000 rpm. Serum is then stored in a closed freezer at -20° C. until analysis of serum sex hormone levels.

Compound 1 and kisspeptin-54 plasma levels are assessed for the first 6 hours to minimize excess blood draw.

As shown in FIG. 15A and 16A, subjects treated with kisspeptin-54 showed an increase in peak LH about 4-6 hours after administration of kisspeptin-54, with an LH surge duration of approximately 14 hours. 16B) and 0.03 nmol/kg Compound 1 (FIGS. 15B and 16C) also showed an increase in LH after administration of Compound 1, however, LH peak levels were reached much later than observed with kisspeptin-54 administration, and the LH surge lasted much longer. (Fig. 17-19). Following a dose of 0.003 nmol/kg of Compound 1, peak serum LH levels were observed between 14-36 hours post-dose and the LH surge continued for approximately 48 hours. For the 0.03 nmol/kg dose of Compound 1, after an initial LH decline, peak serum LH levels were observed between 1820 hours post-administration and the LH surge continued for approximately 14 hours, ending 28 hours post-administration. A longer LH surge is preferred in IVF to promote oocyte maturation. In addition, the observation of a sustained LH surge in the early follicular phase was unexpected, in particular because the kisspeptin-54-induced LH surge lasted only 14 hours compared to the approximately 48 hours observed for a dose of 0.003 nmol/kg of Compound 1.

The slight increase in E2 after administration of compound 1 was similar to that observed for kisspeptin-54 and confirms a similar mechanism of action in stimulating the release of gonadotropins and sex hormones (Fig. 20B). Surprisingly, the FSH response was very low compared to the LH response, which is very different from the results observed for men, who clearly have strong responses to both LH and FSH (Fig. 20A and Example 7, Figs. 8 and 9 ). Additionally, there was some potential desensitization of the FSH response at the 24 and 48 hour time points, also not apparent in males (FIGS. 9 and 20A).

For a dose of 0.003 nmol/kg of Compound 1, results were obtained in only two subjects, since the third subject was considered to be at the bottom of the 4th cycle after a small menstrual bleeding (Fig. 16B). In fact, her period started a few days late and her serum progesterone level confirmed that at the follow-up visit she was in fact in the luteal phase of the previous cycle (day 36).

Part 2. Randomized open crossover studies of the effects of Compound 1 in healthy women.

In this part of the study, the goal is to identify doses of compound 1 (administered during the follicular phase of the menstrual cycle) that provide the most optimal safety, tolerability and pharmacodynamic (PD) profile (namely, LH response) in healthy women. Compound 1 low, intermediate and high doses covering the Compound 1 dose range in Part 1 will be compared with the dose of kisspeptin-54 (9.6 nmol/kg) that effectively induces oocyte maturation during IVF treatment in previous studies, also with the aim of achieving an increase in peak LH response of approximately 10-20% compared with the dose of kisspeptin-54. This will allow you to quickly determine the dose of compound 1, which can subsequently be used as a trigger agent in IVF therapy. The subcutaneous dose of a GnRH agonist (triptorelin 0.2 mg) currently used to induce oocyte maturation in IVF therapy will also be used to provide comparison with Compound 1.

As noted earlier in part 1 of this study, compound 1 was administered during the follicular phase of the menstrual cycle, while this phase (study) is carried out under the conditions of COS as part of ART before IVF. Thus, it is expected that the amplitude of the LH surge will be different from the amplitude of the LH surge observed with the introduction of compound 1 during the follicular phase.

The study population will include 8 healthy women, aged 18-35 years, with a BMI of 18-30 kg/m ² , with no medical problems and not taking any medications or hormonal contraception. The screening visit in these studies will be used to collect the same information as described in Part 1.

This part of the research will consist of six research periods. A follow-up visit will be conducted within 7-10 days after drug administration in each study period. Eight subjects will be randomized to receive a single dose of each of the 6 study regimens (one regimen per study period). All women will be scheduled 6 Day 1 study visits (each during the follicular phase of the menstrual cycle). Each subject will receive a single dose of one of the following 6 study regimens at study day 1 attendance in each study period, such that by the end of that portion of the studies

- 59 041804 each subject received all 6 study regimens (one per study period):

saline (0.9%) 100 µl;

low dose of compound 1, eg 0.003 nmol/kg* or 0.00368 µg/kg (or alternative low dose established after part 1);

intermediate dose of Compound 1, eg 0.01 nmol/kg* or 0.0123 μg/kg (or alternative intermediate dose established after Part 1);

high dose of Compound 1, eg 0.03 nmol/kg* or 0.0368 µg/kg (or alternative high dose established after Part 1);

Kisspeptin-54 9.6 nmol/kg;

GnRH agonist (triptorelin 0.2 mg subcutaneously (SC)).

* For example, a 60 kg woman who is dosed with 0.003 nmol/kg of Compound 1 will receive 0.18 nmol or 0.221 µg. The order in which individual women receive one of the six study regimens will be determined by the randomization matrix.

On study day 1, after a negative urine test confirming no pregnancy, at time zero (0), a single dose (by subcutaneous injection into the abdomen) of Compound 1 (low, eg 0.003 nmol/kg; intermediate, eg , 0.01 nmol/kg; or high, e.g., 0.03 nmol/kg dose), kisspeptin-54 (9.6 nmol/kg), GnRH agonist (triptorelin 0.2 mg), or saline (0. 9%, 100 µl).

Blood sampling, testing, drug storage, and dose preparation are performed as in Part 1.

Part 3. Randomized open crossover studies to evaluate the effects of Compound 1 in women with anovulatory PCOS.

This part of the study aims to compare the pharmacokinetic/pharmacodynamic (PK/PD) profile (in particular LH and FSH response) of the optimal dose of Compound 1 (as determined in part 2 in healthy women) with the PK/PD profile seen in women with anovulatory PCOS. . Women will be diagnosed with anovulatory PCOS with oligomenorrhea (menstrual cycle >35 days), elevated serum AMH (>35 pmol/L), or antral follicle count on ultrasound >23, ± clinical or hormonal evidence of hyperandrogenism. Based on previous studies using kisspeptin-54, women with PCOS are expected to have a similar but slightly increased LH response compared to healthy women. The response to a single dose of compound 1 will also be compared with data for a GnRH agonist (triptorelin 0.2 mg), which is a therapy widely used in women with PCOS to initiate oocyte maturation. This will allow comparison of the optimal dose of Compound 1 (previously determined in Part 2) with the currently standard therapy.

The study population will include women aged 18-35 with anovulatory PCOS.

Screening attendance in these studies will be used to collect the same information as described in Part 1, but with the following two additions.

1) Prior to DI1 (study day 1), women will be induced with Provera (administration of 10 mg twice daily (BID) during the week immediately prior to DI1). 2) After the test-induced run-in period, women will begin each study period, as in parts 1 and 2, beginning on day 1-4 of their test-induced menstrual cycle (follicular phase).

Eight subjects will be randomized to receive a single dose of each of the 4 study drug regimens (one regimen per study period) according to the randomization matrix. All women will be scheduled 4 Day 1 study visits (each during the follicular phase of the menstrual cycle in consecutive months). Each subject will receive a single dose of one of the following four (4) investigational treatment regimens at study day 1 attendance in each study period, such that by the end of that portion of the study period, each subject has received all 4 of the following study treatment regimens (one per study period):

saline (0.9%) 100 µl;

connection 1*;

KP54 9.6 nmol/kg SC (SC);

GnRH agonist (triptorelin 0.2 mg subcutaneously (SC)).

* The dose of Compound 1 will be determined in Part 2 (healthy volunteers) of the studies and the duration of blood sampling for pharmacodynamic (PD) analysis after each study regimen will be determined after Part 1 of the studies, e.g. the duration of blood sampling after (administration of) Compound 1 can be reduced from 14 hours to 8-12 hours, after kisspeptin-54 - up to 8-10 hours, and after saline - up to 6-8 hours.

On Study Day 1, following a negative urine test confirming no pregnancy, at time zero (0), a single dose (by subcutaneous injection into the abdomen) of the optimal dose of Compound 1 (as defined in Part 2 of the studies), kisspeptin-54 will be administered. (9.6 nmol/kg), GnRH agonist (0.2 mg triptorelin) or saline (0.9%,

- 60 041804

100 µl).

Blood sampling, testing, drug storage and dose preparation will be carried out as in Parts 1 and 2.

Listed Implementations

Some embodiments of the invention relate to embodiment I.

Implementation variant I-1. A method for promoting egg maturation and inducing ovulation in assisted reproductive technologies (ART), such as IVF, or in an embryo transfer (ET) process, comprising: administering to a woman a therapeutically effective amount of about 0.001 mg to about 600 mg of 2-(N-acetyl- D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylαlanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or an appropriate amount of a pharmaceutically acceptable salt thereof.

Implementation option I-2. The method according to embodiment I-1, wherein the pharmaceutically acceptable salt is 2-(N-acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanul)hydrazinocαrbonyl- L-leucyl-Nω-methyl-L-αrginyl-L-tryptophanamide monoacetate.

Implementation variant I-3. The method according to embodiment I-1, wherein the therapeutically effective amount is from about 0.001 mg to about 600 mg of 2-(N-acetyl-D-tyrosyl-trans-4hydroxy-L-prolyl-L-asparaginyl-L-threonyl- L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methylL-arginyl-L-tryptophanamide or an appropriate amount of a pharmaceutically acceptable salt thereof is administered by injection.

Implementation variant I-4. The method according to embodiment I-1, wherein the therapeutically effective amount is from about 0.001 mg to about 600 mg of 2-(N-acetyl-D-tyrosyl-trans-4hydroxy-L-prolyl-L-asparaginyl-L-threonyl- L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methylL-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, is administered in a sustained release form, in a single dose.

Implementation variant I-5. The method according to embodiment I-1, wherein -L-arginyl-L-tryptophanamide is represented by the formula

Implementation variant I-6. The method according to embodiment I-2 wherein 2-(K-acetylD-tyrosyl-Ίpance-4-hydroxy-L-prolyl-L-asparaginyl-L-Ίreonyl-L-phenylalanyl)hydrazinocarbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide monoacetate is represented by the formula

H ₃ C

Implementation variant I-7. The method according to embodiment I-1, wherein the introduction of 2-(N- 61 041804 acetyl-O-tyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl-E-threonyl-E-phenylalanyl)hydrazinocarbonylL- leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or a pharmaceutically acceptable salt thereof, induces ovulation in a woman (i) without elevating VEGF levels, or (ii) elevating VEGF levels for less than 24 hours.

Embodiment I-8. A method of promoting egg maturation in an ART, such as IVF, or in a PE process, comprising administering to a woman, by injection, a therapeutically effective amount of about 0.001 mg to about 5 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy -L-prolyl-L-asparaginylL-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment I-9. The method according to embodiment I-8 wherein the pharmaceutically acceptable salt is 2-(N-acetyl-D-turosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl- L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide monoacetate.

Embodiment I-10. The method according to embodiment I-8 wherein the administration is subcutaneous.

Embodiment I-11. The method according to embodiment I-8 wherein the administration is intramuscular.

Embodiment I-12. The method according to embodiment I-8, wherein the administration is intravenous.

Embodiment I-13. The method according to embodiment I-8 wherein 2-(N-acetylD-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide is represented by the formula

Embodiment I-14. The method according to embodiment I-8 wherein 2-(Nacetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl -L-arginyl-L-tryptophanamide monoacetate is represented by the formula:

H ₃ C

Embodiment I-15. A method for promoting egg maturation in an ART, such as IVF, or in a PE process, comprising: administering to a woman, intranasally, a therapeutically effective amount of about 0.001 mg to about 5 mg of 2-(N-acetyl-D-tyrosyl-trans-4- hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment I-16. The method according to embodiment I-15 wherein the pharmaceutically acceptable salt is 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-Ίreonyl-L- phenylαlanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-Ltryptophanamide monoacetate.

Embodiment I-17. The method according to embodiment I-15 wherein 2-(N-acetulD-tyrosyl-trans-4-hydroxy-L-prolyl-L-aspαraginyl-L-threonyl-L-phenylαlanyl)hydrazinoαrbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide is represented by the formula

Embodiment I-18. The method according to embodiment I-15 wherein 2-(N-acetulD-tyrosyl-trans-4-hydroxy-L-prolyl-L-aspαraginyl-L-threonyl-L-phenylαlanyl)hydrazinoαrbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide monoacetate is represented by the formula

H ₃ C

Embodiment I-19. A method of inducing ovulation in ART, such as IVF, or in the process of ET, comprising the following: administering to the woman one or more human gonadotropins, in combination with a GnRH agonist or antagonist (about 2-3 days late) to promote the initial phase of COS and prevent premature ovulation in ART, such as IVF, and/or the PE process, with the initial phase of COS followed by the administration of 2-(N-acetyl-D-turosyl-trans-4-hydroxy-L-prolyl-L-asparaginylL-threonyl-L- phenylαlanyl)hydrazinoαrbonyl-L-leucyl-N ω-methyl-L-arginyl-L-tryptophanamide, or a pharmaceutically acceptable salt thereof, to effectively promote oocyte maturation and induce ovulation (i) without increasing total blood VEGF levels, or (ii) by increasing the overall level of VEGF for a period of less than 24 hours.

Implementation option I-20. The method according to embodiment I-19 wherein the pharmaceutically acceptable salt is 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolylL-asparaginyl-L-threonyl-L-phenylαlanyl)hydrazinocarbonyl- L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide monoacetate.

Embodiment I-21. The method according to embodiment I-19 wherein 2-(K-acetylD-tyrosyl-trans-4-hydroxy-L-prolyl-L-aspαraginyl-L-threonyl-L-phenylαlanyl)hydrazinoαrbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, is administered in an amount of from about 0.001 mg to about 600 mg.

Implementation option I-22. The method according to embodiment I-19 wherein 2-(K-acetylD-tyrosyl-trans-4-hydroxy-L-prolyl-L-aspαraginyl-L-threonyl-L-phenylαlanyl)hydrazinoαrbonyl-Lleucyl-Nω-methyl -L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, is administered by injection in an amount of from about 0.001 mg to about 5 mg.

Implementation variant I-23. The method according to embodiment I-19 wherein 2-(K-acetylD-tyrosyl-trans-4-hydroxy-L-prolyl-L-aspαraginyl-L-threonyl-L-phenylαlanyl)hydrazinoαrbonyl-L-63 041804 leucyl -Rs-methyl-E-arginyl-E-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, is administered intranasally in an amount of from about 0.001 mg to about 5 mg.

Implementation option I-24. The method according to embodiment I-19, wherein one or more human gonadotropins are administered orally or by injection and consist of follicle stimulating hormone, luteinizing hormone, or a combination thereof.

Implementation option I-25. The method according to embodiment I-19 wherein, using a GnRH agonist in the COS phase in the same protocol with 2-(N-acetyl-O-tyrosyl-trans-4-hydroxy-Eprolyl-E-asparaginyl-E-threonyl- E-phenylalanyl)hydrazinocarbonyl-E-leucyl-Ksh-methyl-E-arginyl-Etryptophanamide, or a pharmaceutically acceptable salt, (as trigger agent), the GnRH agonist is a combination of leuprorelin acetate, and when using a GnRH antagonist in the COS phase in one protocol with 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl-Lthreonyl-E-phenylalanyl)hydrazinocarbonyl-E-leucyl-Ksh-methyl-E-arginyl-E-tryptophanamide, or a pharmaceutically acceptable salt, (as trigger agent), the GnRH antagonist is selected from the group consisting of ganirelix, cetrorelix, relugolix, and pharmaceutically acceptable salts of any of the above.

Implementation option I-26. The method according to embodiment I-19 wherein the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, gistrelin, deslorelin, metererelin, lecirelin, and pharmaceutically acceptable salts of any of the above.

Implementation option I-27. The method according to embodiment I-19 wherein the GnRH antagonist is relugolix or a pharmaceutically acceptable salt.

Implementation option I-28. The method according to embodiment I-19 wherein the GnRH antagonist is selected from the group consisting of cetrorelix, ganirelix, abarelix, nal blue, antide, azalin B, degarelix, D63153, relugolix, teverelix, and pharmaceutically acceptable salts of any of the above .

Implementation option I-29. A method for reducing the incidence of OHSS in ART, such as IVF, or in the process of ET, in which 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-E-prolylE-asparaginyl-E-threonyl-) is used as a trigger agent E-phenylalanyl)hydrazinocarbonyl-E-leucyl-Ksh-methyl-E-arginyl-Etryptophanamide or a pharmaceutically acceptable salt, instead of hCG trigger agents.

Implementation option I-30. A method of (providing) a comparable or improved pregnancy rate in ART, such as IVF, or in the process of PE, in which 2-(N-acetyl-O-tyrosyl-trans-4-hydroxy-E-prolyl- E-asparaginyl-E-threonyl-E-phenylalanyl)hydrazinocarbonyl-E-leucyl-Ksh-methyl-E-arginyl-E-tryptophanamide, or a pharmaceutically acceptable salt, instead of GnRH agonist or hCG trigger agents.

Implementation variant I-31. A method for (providing) a shorter pregnancy time in ART, such as IVF, or in the process of PE, in which 2-(N-acetyl-Otyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl is used as a trigger agent -E-threonyl-E-phenylalanyl)hydrazinocarbonyl-E-leucylΝω-methyl-E-arginyl-E-tryptophanamide, or a pharmaceutically acceptable salt, instead of hCG-based trigger agents.

Implementation option I-32. A method for inducing ovulation in an anovulatory cycling woman suffering from secondary ovarian failure, comprising the steps of (1) pre-administering to the subject one or more human gonadotropins, and (2) administering to the subject a therapeutically effective amount of 2-(N-acetyl-U-tyrosyl-trans-4 -hydroxy-E-prolyl-E-asparaginyl-Ethreonyl-E-phenylalanyl)hydrazinocarbonyl-E-leucyl-Ksh-methyl-E-arginyl-E-tryptophanamide, or a pharmaceutically acceptable salt thereof.

Implementation option I-33. A method for preventing premature ovulation in the COS phase of ART, such as IVF, and/or in the process of ET, which uses relugolix, or a pharmaceutically acceptable salt, instead of using a GnRH agonist in the COS phase.

Some embodiments of the invention relate to implementation variant II.

Embodiment II-E A method of increasing endogenous LH in a woman in need, comprising: administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetylD-tyrosyl-trans-4-hydroxy-E-prolyl -E-asparaginyl-E-threonyl-E-phenylalanyl)hydrazinocarbonyl-Eleucyl-Ksh-methyl-E-arginyl-E-tryptophanamide, or an appropriate amount of its pharmaceutically acceptable salt, in which a woman undergoes ART procedures and is at risk of OHSS, and after the introduction of the initial dose, the level of endogenous LH in the blood of a woman is increased compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Implementation variant II-2. A method for increasing the level of endogenous LH in a woman undergoing ART procedures in need thereof, comprising: administering to the woman an initial dose of from about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-O-tyrosyl-trans-4-hydroxy-E- prolyl-E-asparaginyl-Ethreonyl-E-phenylalanyl)hydrazinocarbonyl-E-leucyl-Ksh-methyl-E-arginyl-E-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, in which the woman undergoes ART procedures, and at least 36 hours after the initial dose, the level of endogenous LH in the woman's blood is increased compared to the level of endogenous LH in the woman's blood before the initial dose.

Implementation variant II-3. A method for increasing endogenous LH levels in a woman undergoing ART in need thereof, comprising: administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L- prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl) hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of its pharmaceutically acceptable salt, in which a woman undergoes ART procedures, and the maximum level of endogenous LH in the blood is observed at least about 12 hours after the initial dose.

Embodiment II-4. The method according to embodiment II-3, wherein the maximum level of endogenous LH in the blood occurs between about 12 hours and about 48 hours after the initial dose.

Embodiment II-5. A method for increasing endogenous LH levels in a woman undergoing ART procedures and in need of luteal phase support, comprising administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy- L-prolyl L-asparaginyl-L-threonyl-L-phenylalanyl) hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, following the woman's indicated trigger dose of an oocyte maturation agent as part of the regimen ART.

Embodiment II-6. The method according to one of the preceding Embodiments, wherein the woman's endogenous LH blood level is elevated between about 12 hours and about 96 hours after the initial dose is administered compared to the woman's endogenous LH blood level before the initial dose is administered.

Embodiment II-7. The method according to one of the preceding embodiments, wherein the woman's endogenous LH blood level is elevated for at least 36 hours after the initial dose is administered compared to the woman's endogenous LH blood level prior to the initial dose.

Embodiment II-8. The method according to embodiment II-7, wherein the level of endogenous LH in the blood is elevated for about 36 hours to about 16 days.

Embodiment II-9. The method according to embodiment II-7, wherein the level of endogenous LH in the blood is elevated for about 36 hours to about 12 days.

Embodiment II-10. The method according to one of the preceding Embodiments, wherein administration of the initial dose promotes oocyte maturation.

Embodiment II-11. The method according to embodiment II-10 wherein oocyte maturation occurs without administration of exogenous hCG or exogenous LH.

Embodiment II-12. The method according to embodiment II-10 or II-11 wherein oocyte maturation occurs following administration of a GnRH agonist.

Embodiment II-13. The method according to embodiment II-10 wherein oocyte maturation occurs after administration of exogenous hCG.

Embodiment II-14. The method according to any of the embodiments of II-10-II-13, wherein the yield of mature oocytes is at least 50%.

Embodiment II-15. The method according to one of the preceding embodiments, wherein, after administration of the initial dose, the woman does not experience one or more symptoms selected from the group consisting of ascites, pleural effusion, and decreased renal perfusion.

Embodiment II-16. The method according to one of the preceding embodiments wherein, after administration of the initial dose, the size of the ovary is increased to no more than 5 cm in diameter.

Embodiment II-17. The method according to one of the preceding embodiments, wherein the woman does not experience one or more of the symptoms of OHSS after administration of the initial dose.

Embodiment II-18. The method according to any one of embodiments II-1-II-16 wherein, after administration of the initial dose, the woman experiences no worsening of one or more of the symptoms of OHSS.

Embodiment II-19. The method according to one of the preceding embodiments, wherein the initial dose is administered when at least three ovarian follicles of at least 14 mm are observed by ultrasound.

Embodiment II-20. The method according to one of the preceding embodiments, wherein the initial dose is administered when at least three ovarian follicles of at least 18 mm are observed by ultrasound.

Embodiment II-21. The method according to one of the preceding embodiments wherein the initial dose is administered when the serum estradiol concentration is at least 0.49 nmol/l.

Embodiment II-22. The method according to one of the preceding embodiments, wherein the method further comprises administering FSH from about 5 days to about days prior to the initial dose.

Embodiment II-23. The method according to one of the preceding embodiments, further comprising administering the GnRH antagonist from about 2 days to about 10 days prior to the initial dose.

Embodiment II-24. The method according to embodiment II-23 wherein the GnRH antagonist is selected from the group consisting of relugolix, elagolix, cetrorelix, ganirelix, abarelix, nal blue, antide, azalin B, degarelix, D63153 (ozarelix), OVE2109, and teverelix.

Embodiment II-25. The method of any one of embodiments II-1-II-24 further comprising administering the GnRH agonist from about 14 to about 28 days prior to the initial dose.

Embodiment II-26. The method according to embodiment II-25 wherein the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, gistrelin, deslorelin, metererelin, and lecirelin.

Embodiment II-27. A method according to one of the preceding embodiments wherein the initial dose is administered prior to oocyte retrieval.

Embodiment II-28. The method according to any of the embodiments of II-1-II-27, wherein the initial dose is administered after oocyte retrieval.

Embodiment II-29. The method according to any of the embodiments of II-1-II-27 wherein the initial dose is administered prior to ovulation.

Embodiment II-30. The method according to any of the embodiments of II-1-II-27, wherein the initial dose is administered after ovulation.

Embodiment II-31. The method according to one of the preceding embodiments, wherein the initial dose is administered following the administration of a GnRH agonist as an oocyte maturation agent.

Embodiment II-32. The method according to embodiment II-31 wherein the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, gistrelin, deslorelin, metererelin, and lecirelin.

Embodiment II-33. The method according to one of the preceding embodiments, further comprising administering a second dose of about 0.00003 mg to about 0.030 mg of 2-(Nacetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-G- threonyl-G-phenylalanyl)hydrazinocarbonyl L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-34. The method according to embodiment II-33, wherein the second dose is administered over a period of about 8 to about 60 hours after the initial dose.

Embodiment II-35. The method according to embodiment II-33 or II-34 further comprising administering a third dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetylD-tyrosyl-trans-4-hydroxy-L-prolyl-L- asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-Lleucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-36. The method according to embodiment II-35, wherein the third dose is administered over a period of about 8 to about 60 hours after the second dose is administered.

Embodiment II-37. The method according to embodiment II-35 or II-36 further comprising administering one to five additional doses of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy- L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-38. The method according to embodiment II-37, wherein one to five additional doses are administered over a period of about 8 to about 60 hours after the previous additional dose is administered.

Embodiment II-39. The method according to one of the preceding embodiments, further comprising administering one or more doses of a progestogen.

Embodiment II-40. The method according to any of the embodiments of II-1-II-38, wherein the method does not include administering one or more doses of a progestogen.

Embodiment II-41. A method according to one of the preceding embodiments, further comprising retrieval of oocytes.

Embodiment II-42. The method according to embodiment II-41 wherein the woman's pituitary gland is desensitized to GnRH before the initial dose is administered.

Embodiment II-43. A method according to one of the preceding embodiments, further comprising implanting an embryo.

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Embodiment II-44. The method according to embodiment II-43, wherein implantation occurs within about 2 to about 10 days after the initial dose.

Embodiment II-45. The method according to embodiment II-43 or II-44 wherein implantation occurs within about 1 to about 7 days after oocyte retrieval.

Embodiment II-46. The method according to any of the embodiments of II-43-II-45 wherein the embryo is not frozen.

Embodiment II-47. The method according to embodiment II-46 wherein the embryo is implanted in the same menstrual cycle as the oocyte retrieval.

Embodiment II-48. The method according to any of the embodiments of II-1-II-23, II-25II-26, or II-28-II-30, wherein the method induces ovulation.

Embodiment II-49. The method according to embodiment II-48, wherein the woman becomes pregnant through intercourse or intrauterine insemination after at least the initial dose has been administered.

Embodiment II-50. The method according to one of the preceding embodiments, wherein after administration of at least the initial dose, the woman becomes pregnant and/or gives birth.

Embodiment II-51. The method of any one of embodiments II-1-II-4 or II-6-II-50, wherein one or more initial doses, a second dose, a third dose, or one to five additional doses promote luteal phase support.

Embodiment II-52. The method according to one of the preceding embodiments, wherein one or more initial doses, a second dose, a third dose, or one to five additional doses are administered by injection.

Embodiment II-53. The method according to embodiment II-52, wherein the injection is an intramuscular or subcutaneous injection.

Embodiment II-54. The method according to one of the preceding embodiments, wherein any of one or more initial doses, second dose, third dose, or one to five additional doses is from about 0.0003 mg to about 0.03 mg.

Embodiment II-55. The method according to one of the preceding embodiments wherein the woman is undergoing COS.

Embodiment II-56. The method according to one of the preceding embodiments, wherein the ART therapy is selected from the group consisting of oocyte donation, oocyte banking, intracytoplasmic sperm injection (ICSI), IVF, embryo transfer process (ET), ovulation induction, and intrauterine insemination.

Embodiment II-57. The method according to one of the preceding embodiments, wherein the woman has one or more of PCOS, serum AMH greater than 15 pmol/l, total AFR greater than 23 on ultrasound, serum estradiol E2 greater than 3000 pg/ml, or has had one or several previous episodes of OHSS.

Embodiment II-58. The method according to one of the preceding embodiments, wherein the woman has one or more of the anovulatory cycles, or advanced reproductive age, or is experiencing secondary ovarian failure, oligomenorrhea, amenorrhea, endometriosis, or polycystic ovarian syndrome (PCOS).

Embodiment II-59. A method for inducing final maturation of follicles and early luteinization in a woman in need thereof, wherein said woman is undergoing ART procedures, has undergone pituitary desensitization and has previously received follicle-stimulating hormones as part of ART, comprising administering to the woman an initial dose of from about 0.00003 mg to about 0.030 mg of 2- (N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-K ω-methyl-L-arginyl-L-tryptophanamide, or the corresponding amount of its pharmaceutically acceptable salt, and after administration of the initial dose, the level of endogenous LH in the blood of a woman is increased compared to the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Embodiment II-60. A method for inducing ovulation in a woman in need, wherein said woman is anovulatory infertile and said infertility is not caused by a primary ovarian dysfunction, comprising administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl -trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-K ω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof, and after the introduction of the initial dose, the level of endogenous LH in the blood of a woman is increased compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Embodiment II-61. The method according to embodiment II-59 or II-60 wherein the woman is at risk for OHSS.

Embodiment II-62. The method according to any of the embodiments of II-59-II-61, wherein at least 36 hours after the initial dose, the level of endogenous LH in the woman's blood

- 67 041804 increased compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Embodiment II-63. The method according to any one of the embodiments of II-59-II-62, wherein the maximum level of endogenous LH in the blood is observed at least about hours after the initial dose.

Embodiment II-64. The method according to embodiment II-63, wherein the maximum level of endogenous LH in the blood occurs between about 12 hours and about 48 hours after the initial dose.

Embodiment II-65. The method according to any of embodiments II-59-II-64, wherein the woman's endogenous LH blood level is elevated between about 12 hours and about 96 hours after the initial dose is administered compared to the woman's endogenous LH blood level before the initial dose is administered .

Embodiment II-66. The method according to any one of embodiments II-59-II-65, wherein the woman's endogenous LH blood level is elevated for at least 36 hours after the initial dose compared to the woman's endogenous LH blood level before the initial dose.

Embodiment II-67. The method according to embodiment II-66, wherein the level of endogenous LH in the blood is elevated for about 36 hours to about 16 days.

Embodiment II-68. The method according to embodiment II-66, wherein the level of endogenous LH in the blood is elevated for about 36 hours to about 12 days.

Embodiment II-69. The method according to one of the preceding embodiments wherein the woman experiences anovulatory infertility not caused by a primary ovarian dysfunction.

Embodiment II-70. A method according to one of the preceding embodiments comprising administering to the woman an initial dose of about 0.001 mg to about 0.003 mg of 2-(N-acetylD-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl- L-phenylalanyl)hydrazinocarbonyl-Lleucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-71. The method according to any one of embodiments II-1-II-69 comprising administering to the woman an initial dose of about 0.001 mg to about 0.030 mg of 2-(M-acetyl-Otyrosyl-trans-4-hydroxy-L-prolyl-L- asparaginyl-L-Ίreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-72. The method according to any one of embodiments II-1-II-69, comprising administering to the woman an initial dose of about 0.0003 mg to about 0.003 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl- L-asparaginyl-L-Ίreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-73. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or a pharmaceutically acceptable salt thereof, for use in a method for increasing endogenous LH levels in a woman undergoing ART procedures at risk of OHSS, comprising: administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl -trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-74. 2-N-Acetyl N-tyrosyl-trans-4-hydroxy-I-prolyl I-asparaginyl I-threonyl-L-phenylalanyl) hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof, for use in accordance with Implementation variant II-73, and after the introduction of the initial dose, the level of endogenous LH in the blood of a woman is increased compared to the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

Embodiment II-75. 2-N-Acetyl N-tyrosyl-trans-4-hydroxy-I-prolyl I-asparaginyl I-threonyl-L-phenylalanyl) hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or a pharmaceutically acceptable salt thereof, for use in a method for increasing endogenous LH levels in a woman undergoing ART procedures, comprising: administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L -asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-76. 2-N-Acetyl N-tyrosyl-trans-4-hydroxy-I-prolyl I-asparaginyl I-threonyl-L-phenylalanyl) hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof, for use in accordance with implementation II-75, and at least 36 hours after the initial dose, the level of endogenous LH in the blood of a woman is increased compared with the level of endogenous LH in the blood of a woman before the introduction of the initial dose.

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Embodiment II-77. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with embodiment II-75, wherein the peak endogenous LH blood level occurs at least about hours after the initial dose is administered.

Embodiment II-78. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use according to embodiment II-75 wherein the woman receives a trigger dose of an oocyte maturation agent as part of an ART regimen prior to the initial dose of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl -L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof.

Embodiment II-79. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the initial dose is administered when at least three ovarian follicles of at least 14 mm are observed by ultrasound.

Embodiment II-80. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the initial dose is administered when at least three ovarian follicles of at least 18 mm are observed by ultrasound.

Embodiment II-81. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the initial dose is administered when the serum estradiol concentration is at least 0.49 nmol/l.

Embodiment II-82. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, further comprising administering FSH from about 5 days to about 12 days prior to the initial dose.

Embodiment II-83. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, further comprising administering the GnRH antagonist from about 2 days to about 10 days prior to the initial dose.

Embodiment II-84. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use according to embodiment II-83, wherein the GnRH antagonist is selected from the group consisting of relugolix, elagolix, cetrorelix, ganirelix, abarelix, nal-blue, antide, azaline B, degarelix, D63153 (ozarelix), OVE2109 and teverelix.

Embodiment II-85. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the embodiments of II-73-II-84, further comprising administering the GnRH agonist from about 14 to about 28 days prior to the initial dose.

Embodiment II-86. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use according to embodiment II-85, wherein the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, gistrelin, deslorelin, metererelin, and lecirelin.

Embodiment II-87. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the initial dose is administered prior to oocyte retrieval.

Embodiment II-88. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-Gthreonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the embodiments of II-73-II-87, wherein the initial dose is administered after oocyte retrieval.

Embodiment II-89. 2-(M-Acetyl-O-tyrosyl-trans-4-hydroxy-G-prolyl-G-asparaginyl-G- 69 041804 threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L -tryptophanamide or a pharmaceutically acceptable salt thereof, for use in any of the embodiments

11-73-11-87, and the initial dose is administered before ovulation.

Embodiment II-90. 2-H-AcetylO-tyrosyl-trans-4-hydroxy-prolyl-asparaginyl-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof for use in accordance with any of embodiments II-73 - II-87, wherein the initial dose is administered after ovulation.

Embodiment II-91. 2-H-AcetylO-tyrosyl-trans-4-hydroxy-prolyl-asparaginyl-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof for use in accordance with any of the preceding embodiments, wherein the initial dose is administered after administration of the GnRH agonist as an oocyte maturation agent.

Embodiment II-92. 2-H-AcetylJu-tyrosyl-trans-4-hydroxy-prolyl-asparaginyl-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof for use according to the embodiment implementation of II-91, and the GnRH agonist is selected from the group consisting of leuprorelin acetate, gonadorelin, buserelin, triptorelin, goserelin, nafarelin, gistrelin, deslorelin, metererelin and lecirelin.

Embodiment II-93. 2-H-AcetylO-tyrosyl-trans-4-hydroxy-prolyl-asparaginyl-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof for use in accordance with any of the preceding embodiments, further comprising administering a second dose of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl )hydrazinocarbonyl-L-leucyl-N ω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-94. 2-H-AcetylJu-tyrosyl-trans-4-hydroxy-prolyl-asparaginyl-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or a pharmaceutically acceptable salt thereof for use according to the embodiment implementation of II-93, and the second dose is administered over a period of from about 8 to about 60 hours after the initial dose.

Embodiment II-95. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-n-rolyl-L-asparaginyl-Lthreonyl-L-phenylαlanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-αrginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with embodiment II-93 or II-94, further comprising administering a third dose of about 0.00003 mg to about 0.030 mg of 2-(Nacetyl-O-tyrosyl-trans-4-hydroxy-E- prolyl-E-asparaginyl-E-threonyl-L-phenylalanyl)hydrazinocarbonyl L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-96. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with embodiment II-95, wherein the third dose is administered over a period of about 8 to about 60 hours after the second dose.

Embodiment II-97. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with Embodiment II-95 or II96, further comprising administering one to five additional doses of about 0.00003 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyl-trans-4- hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-N ω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-98. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with embodiment II-97, wherein one to five additional doses are administered over a period of about 8 to about 60 hours after the previous additional dose is administered.

Embodiment II-99. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, further comprising administering one or more doses of a progestogen.

Embodiment II-100. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the embodiments of II-73-II-98, wherein the method does not include administering one or more doses of a progestogen.

- 70 041804

Embodiment II-101. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein one or more initial doses, a second dose, a third dose, or one to five additional doses are administered by injection.

Embodiment II-102. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use according to embodiment II-101, wherein the injection is an intramuscular or subcutaneous injection.

Embodiment II-103. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein any one or more initial doses, a second dose, a third dose, or one to five additional doses is from about 0.0003 mg to about 0.03 mg.

Embodiment II-104. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the woman is undergoing COS.

Embodiment II-105. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the ART therapy is selected from the group consisting of oocyte donation, oocyte banking, ICSI, IVF, PE process, ovulation induction, and intrauterine insemination.

Embodiment II-106. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the woman has one or more of PCOS, serum AMH greater than 15 pmol/l, total AFR greater than 23 on ultrasound, serum estradiol E2 greater than 3000 pg/ml, or has had one or more previous episodes of OHSS.

Embodiment II-107. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the woman has one or more of anovulatory cycles, or advanced reproductive age, or is experiencing secondary ovarian failure, oligomenorrhea, amenorrhea, endometriosis, or polycystic ovarian syndrome (PCOS) .

Embodiment II-108. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in a method of inducing terminal follicular maturation and early luteinization in an ART woman who has undergone pituitary desensitization and has previously received follicle-stimulating hormones as part of ART, comprising administering to the woman an initial dose of about 0.00003 mg to about 0.030 mg of 2- (M-acetyl-Otyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl-E-1rheonyl-E-phenylalanyl)hydrazinocarbonyl-E-leucylNω-methyl-L-arginul-L-tryptophanamide, or a pharmaceutically appropriate amount thereof acceptable salt.

Embodiment II-109. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with embodiment II-108, wherein after administration of the initial dose, the level of endogenous LH in the woman's blood is increased compared to the level of endogenous LH in the woman's blood before the administration of the initial dose.

Embodiment II-110. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in a method for inducing ovulation in an anovulatory infertile woman, said infertility not being caused by a primary ovarian dysfunction, comprising administering to the woman an initial dose of 0.00003 mg to about 0.030 mg of 2-(Nacetyl-O-tyrosyl-trans -4-hydroxy-E-prolyl-L-asparaginyl-E-threonyl-E-phenylalanyl)hydrazinocarbonyl L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof.

Embodiment II-111. 2-(N-Adetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with embodiment II-110, wherein after administration of the initial dose, the level of endogenous LH in the woman's blood is increased compared to

Claims (3)

niyu with the level of endogenous LH in the blood of a woman before the introduction of the initial dose. Embodiment II-112. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the embodiments II-108 - II-111, and the woman is at risk of OHSS. Embodiment II-113. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the preceding embodiments, wherein the starting dose is 0.001 mg to about 0.003 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-E-prolyl-E-asparaginyl-E- threonyl-E-phenylalanyl)hydrazinocarbonyl-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof. Embodiment II-114. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the embodiments of II-73-II-112, wherein the starting dose is from 0.001 mg to about 0.030 mg of 2-(N-acetyl-D-tyrosyltrans-4-hydroxy-L-prolyl- L-asparaginyl-L-threonyl-L-phenylalanyl)-hydrazinocarbonyl-L-leucylNω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof. Embodiment II-115. 2-(N-Acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or its a pharmaceutically acceptable salt for use in accordance with any of the embodiments of II-73-II-112, wherein the starting dose is from 0.0003 mg to about 0.003 mg of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-E- prolyl-E-asparaginyl-E-threonyl-E-phenylalanyl)-hydrazinocarbonyl-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide, or an appropriate amount of a pharmaceutically acceptable salt thereof. Embodiment II-116. Use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-Ltryptophanamide, or its a pharmaceutically acceptable salt, in the manufacture of a drug to increase endogenous LH levels in a woman undergoing ART procedures at risk of OHSS. Embodiment II-117. Use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-Ltryptophanamide, or its a pharmaceutically acceptable salt, in the manufacture of a drug to increase endogenous LH levels in a woman undergoing ART procedures. Embodiment II-118. Use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-Ltryptophanamide, or its a pharmaceutically acceptable salt, in the manufacture of a drug for inducing final follicular maturation and early luteinization in an ART woman undergoing pituitary desensitization and previously treated with follicle-stimulating hormones as part of ART. Embodiment II-119. Use of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-Lasparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-Ltryptophanamide or its pharmaceutical acceptable salt in the manufacture of a medicament for inducing ovulation in a woman who is anovulatory infertile, said infertility not being caused by a primary ovarian dysfunction. CLAIM 1. Application of 2-(N-acetyl-D-tyrosyl-trans-4-hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L- tryptophanamide or a pharmaceutically acceptable salt thereof to increase the level of endogenous luteinizing hormone (LH) in a woman undergoing assisted reproductive technology (ART) procedures, where the initial dose is from 0.003 to 0.015 mg 2-(N-acetyl-D-tyrosyl-trans-4- hydroxy-L-prolyl-L-asparaginyl-L-threonyl-L-phenylalanyl)hydrazinocarbonyl-L-leucyl-Nω-methyl-L-arginyl-L-tryptophanamide or an appropriate amount of a pharmaceutically acceptable salt thereof is administered to said woman and where the maximum level of endogenous LH in blood is observed between 12 hours and 48 hours after the initial dose. 2. The use according to claim 1, characterized in that the maximum level of endogenous LH in the blood is observed between 18 hours and 48 hours after the initial dose. 3. The use according to claim 1 or 2, characterized in that the maturation of oocytes occurs without the introduction of exogenous human chorionic gonadotropin or exogenous LH. -