TOPRA Annual Veterinary Symposium

Reproductive
Toxicity Testing:
What and Why?

A presentation by Sally Clode, Principal Reproduction

Toxicologist, Sequani Limited

ENABLING AND PROMOTING EXCELLENCE IN THE HEALTHCARE REGULATORY PROFESSION

 In this presentation we will cover

The aims of reproduction toxicology studies

ICH Guidelines

The basic reproductive cycle

How certain drugs can affect the cycle

Study designs

Biotechnology products

Clinical Trials

Labelling

Summary

Data presentation.
 Aim of Reproduction Toxicology
Studies

ICHS5 Guideline:

The studies conducted should allow exposure of mature

adults and all stages of development to sexual maturity
 ICH Guidelines

The main guideline for reproduction studies was adopted in

1993:
ICHS5
An addendum to S5 to cover effects on male fertility was issued
in 2000.
In terms of reproduction studies, the
M3(R2) Guidance on Non-Clinical Safety Studies for the
Conduct of Human Clinical Trials and Marketing
Authorization for Pharmaceuticals
issued 2009, relaxed the requirement for non-clinical
studies to support trials in women of childbearing
potential.
The basic reproductive cycle
 Within this cycle, we divide it up into an
integrated sequence.for convenience

Pre-Mating to conception

Conception to implantation

Implantation and organ formation

Organ formation to end of pregnancy

Birth to Weaning

Weaning to sexual maturity

(ICH S5A Guideline)
 Drug adverse effects on different stages of the
cycle:

Pre-mating to conception
- Fertilisation disruption gossypol (antimalarial)
- Abnormal sperm motility caffeine
- Effects on libido alcohol
- Disrupted egg release steroid hormones
Implantation
- Diethylstilbestrol (hormone)
- Anti-histamines
 Drug adverse effects on different stages of the
cycle (continued):

Foetal development
- Abnormal foetal growth and development alcohol
- Abnormal foetal neurobehavioural development heroin,
cocaine
Foetal malformations
- Thalidomide anti-emetic
- Gossypol antimalarial
- DES synthetic oestrogen
- Ergotomine migraine
- Aspirin acute pain
 Drug adverse effects on different stages of the
cycle (continued)

Birth
- Premature birth (miscarriage) ergotomine
- Delayed birth progesterone
- Foetal difficulties aspirin
Lactation abnormal development of the offspring due to
either direct exposure during pregnancy or transfer via milk
- Alcohol
- Anti-depressants
- Methyl mercury
 Drug adverse effects on different stages of the
cycle (continued)

Sexual maturation
- Altered sperm maturation colchicine (spindle inhibitor)
- Lower sperm count cyclophosphamide
- Altered ovulation testosterone propionate
 Study Designs

The ICHS5 guideline recommends:

- flexibility study design

- avoid suffering
- minimum number of animals necessary
- make use of existing data

For most medicinal products, the ICH recommend that the 3-

study design will usually be adequate for rodents which covers
all stages of development
 3-Study Design

1. Fertility and early embryonic development -Rat

- Pre-mating to implantation
2. Embryo-Foetal development Rat and Rabbit
- Organogenesis
3. Pre- and postnatal development Rat
- Implantation to weaning

Studies may be combined

 1. Fertility and Early Embryonic
Development Study

Usually conducted in rats

May be done separately male or female fertility assessment or
together
Also known as Segment I study
Multi-faceted & complex!
Male & Female gamete production and release
Appropriate psycho-sexual behaviour for mating
Pre-implantation stages of the embryo
Implantation and viability of resultant zygote
 Fertility and Early Embryonic Development
Study Design

Group size = 22 Males and 22 Females

Female
Female Caesarean & Uterine Male
Start Dosing Mating
Last Dose examination Necropsy

14 Days 14 Days

Day G0 Day G6 Day G13

Dosing period G = Day of gestation

 Endpoints in a Fertility Study

Males
Testicular and epididymal weights*
Testicular and epididymal histopathology*
Sperm assessment*
Mating behaviour and pre-coital intervals
Females
Oestrus cyclicity
Ovarian weight and histopathology*
Number of corpora lutea, implants, live and dead embryos
Pre-coital interval
And Fertility of Both!
* most are optional
 Embryo-Foetal
Development Study

Usually conducted in 2 species: rat and rabbit

Also known as the Segment II study or the Teratology
study
Have to use the correct species
at the correct time
at the correct dose
 Why 2 Species?

Genotype influences response to exogenous agents

Two species better than one at detecting hazard

No species is intrinsically best at predicting for man

Aim to have at least one pharmacologically relevant

species
 Species factors for consideration

Maternal weight

Litter size

Maternal basic metabolic rate

Size and constitution of placenta

Hormones/vitamins etc
 Species - continued

RAT RABBIT

For: For:
- good size - non-rodent
- Highly fertile - Optimal foetal size
- Genetic stability - Malformation rate approx.,
(background data) equal to human

Against: Against:
- Low spontaneous - Absence of pure strains
malformation rate - Lack of kinetic/toxicity data
- Low sensitivity to - Susceptible to antibiotics
teratogens - Gastric disturbances
- Sensitive to sex hormones
- Susceptible to NSAIDs in
late pregnancy
 Species - continued

Less commonly.
Mice, mini-pigs, non-human primates, hamsters
In vitro (for special investigations) e.g. rat embryo culture and
embryonic stem cells
 2. Embryo-Foetal Development Study Design

Rats/Rabbits

Gestation

Day 0 Day 6/7 Day 17/18 Day 20/28

Dosing Period
Blastocyst implantation to
closure of hard palate
Caesarian

In rats or rabbits
4 groups: 16 to 20 litters
Dams: Monitor body Foetal: External, soft tissue
weights, food consumption, and skeletal examination
clinical obs etc
 Endpoints in an embryo-foetal development
study:

DAM
Clinical observations
Weight gain & food consumption
Number of implants and foetuses
Post-implantation loss
FOETUS
Foetal & placental weights
External abnormalities
Soft tissue abnormalities
Skeletal abnormalities
Death & retarded development
 Rat Gravid Uterus

Intact uterus multiple implants

VAGINA
 Rat opened uterine horn

Foetuses still attached to placentae

 Individual Rat Foetus

Uterine horn opened attached to placenta

 Foetal Examinations

Soft tissue: Fresh dissection or fixed tissue

Bouins fixed
Freehand serial sections (Wilson 1965)
Fixed dissection (Barrow & Taylor 1969) more
usual fixed method

Skeletal exam: Alizarin stained (or alizarin/alcian blue

double staining)
Techniques must be rapid & robust to cope with large
number of foetuses

(Up to ~20 foetuses per litter, 80 litters/study = 1000+

foetuses)
Foetal examination continued.

Rat Foetus Day 20 of gestation

Bouins fixation to allow examination
of viscera by serial sectioning
 Foetal examination continued.

Rat Foetus Day 20 of gestation

Double Staining

Processed and stained.

Alizarin red S (ossified) &
Alcian Blue (cartilaginous)
 Interpretation of embryo-foetal study data

Triad of Effects:
Embryo-foetal deaths, reduced foetal weight, morphologic
abnormalities
Unit of statistical interest is the litter:
Defects in a few foetuses from several litters may be more indicative
of a compound effect than many affected foetuses in one litter
Compound effects can be subtle:
e.g. delays in ossification of certain bones
e.g. increased incidence of a normal variation
Background data are very helpful
Tracking the occurrence of low incidence lesions in the control
or untreated rat and rabbit aids data interpretation
 Interpretation of embryo-foetal study data

Influence of maternal toxicity is controversial:

Aim is NOT to cause maternal toxicity but if foetal defects occur in
dams showing toxicity, what does that mean?

Study aim is to detect hazard, not characterise risk!

Hazard: Potential to cause harm
Risk: Likelihood to cause harm

Extrapolating from results in animals to what might happen in humans

look at all available data & assess relevance
Additional studies may be required to explain results and help
determine relevance for humans case by case basis
 3. Pre and Postnatal Development Study
Design

P generation females
G6 G22 Day 22 pp

F1 generation
Day 0 pp

F1 survival, growth F1
and behavioural tests mate

Rats: 4 groups 16 to 20 litters

 End-points in a Pre and Postnatal Development
Study

Dam
Weight gain & food consumption etc
Gestation and parturition length
Changes & behaviour during lactation
Pups
Survival, weight gain, sex ratio,
Physical development (pinna detachment, coat growth,
locomotion, eyes open etc)
Behavioural development (motor activity, water maze
learning and memory, startle responses etc)
Repro performance of F1 (to mid-gestation)
Note : Doesnt deal with direct exposure of offspring from
weaning Juvenile Tox studies required for direct exposure
through to maturity
 Biotechnology Derived Products

ICH HARMONISED TRIPARTITE GUIDELINE

PRECLINICAL SAFETY EVALUATION OF

BIOTECHNOLOGY-DERIVED PHARMACEUTICALS
S6(R1)

Parent Guideline dated 16th July 1997

Current Step 4 version
Addendum dated 12 June 2011 incorporated at the end of June 2011
 Reproduction Studies

For products pharmacologically active only in NHPs,

several study designs can be considered based on
intended clinical use and expected pharmacology,
Separate embryo-foetal development (EFD) and/or pre
and postnatal studies (PPND), or other study designs can
be appropriate, particularly if there is some concern that
the mechanism of action might lead to an adverse effect
on embryo-foetal development or pregnancy loss.

One well-designed study in NHPs which includes dosing

from Day 20 of gestation to birth (the enhanced PPND,
ePPND) can be considered, rather than separate EFD
and/or PPND studies.
Clinical Trials
 Reproduction Studies Relative to
Clinical Trials

Men
Men can be included in Phase I (volunteers) and Phase II
(patients) trials before the conduct of a male fertility study
reproductive organs are assessed in general toxicology
studies.
A male fertility study should be completed before the
initiation of large scale or long duration clinical trials
Phase III
 Reproduction Studies Relative to
Clinical Trials
Women
Women not of childbearing potential can be included without
reproduction studies if reproductive organs are assessed in
general toxicology studies.
For women of childbearing potential there are two options:
Conduct appropriate reproduction studies and take
appropriate precautions
Do no definitive reproduction studies but take precautions
to prevent pregnancy by pregnancy testing, use of highly
effective methods of birth control and entry to trials only
after a confirmed menstrual period.
 Reproduction Studies Relative to
Clinical Trials
Women of Childbearing potential
In USA assessment of embryo-foetal development (EFD) and female fertility
can be deferred to Phase III with use of adequate precautions to prevent
pregnancy.
In EU and Japan appropriate preliminary EFD studies are required in 2
species. Definitive studies can be deferred until studies of >3 months
or >150 patients are required (normally Phase III).
Based on low rate of pregnancy in clinical trials
Adequacy of preliminary studies to detect hazard

Female fertility studies can be deferred to Phase III

In all regions the pre-and postnatal study is required for marketing
approval

Clinicians should always be aware of any class history of reproductive

hazard of the test material
 THE LABEL

Different Approaches in USA and Europe

 Purpose of Label

Fulfil regulatory requirements

Provide guidance for physicians to make clinical

decisions in the best interests of the patient

Minimise liability problems full disclosure

 How to Communicate Risk

Describe potential hazard

Interpret relevance for humans

Indicate critical stages of pregnancy

Give advice that takes into account the therapeutic

benefit of the drug

Update with relevant human data as available (number

of pregnancies?)
 Pharmaceutical Pregnancy Labelling in
the USA
FDA classification (2009)

%
A Controlled studies show no risk 0.7
B No evidence of risk in human 19
C Risk cannot be ruled out 66
D Positive evidence of risk 7
X Contraindicated with little benefit 7

Too many in an unhelpful category !

Background incidence of defects in human approx 3%

Often difficult to get enough data to tell if real human risk or
not
 EU Pregnancy Label
A text based approach without defined categories

4.6 Pregnancy and Lactation

There are no adequate and well controlled studies with Cure-ital in pregnant
women. Animal studies have shown no teratogenic effects or impaired growth.

Although no data exist in humans, excretion of Cure-ital in breast milk has

been seen in animals. Caution should be exercised when considering the
administration of Cure-ital to a nursing woman.

Guideline on Summary of Product Characteristics: (Pharmaceutical Committee,

December 1999)
Rules Governing Medicinal Products in the European Union, Volume 2A and 2B: Notice
to Applicants
http://pharmacos.eudra.org/F2/pharmacos/docs/Doc2000/SPCGuidRev0-Dec99.pdf
 SUMMARY

Harmonised guidelines (EU, US and Japan) exist for

testing new medicinal products
The entire reproductive cycle is covered by these
tests; no gaps; performed during different phases of
drug development
Support of Clinical Trials What and When?
Risk assessment and Product Labels
References:

INTERNATIONAL CONFERENCE ON
HARMONIZATION (ICH)

http://www.eudra.org/humandocs/humans/ich.htm

- S5a Note for Guidance on Reproductive Toxicology:

Detection of Toxicity to Reproduction for Medicinal Products
(CPMP adopted Sept 1993)
- S5b Note for Guidance on Reproductive Toxicology: Toxicity
on Male Fertility (CPMP adopted Dec, 1995)
- S5b Guideline on Detection of Toxicity to Reproduction for
Medicinal Products; Addendum on Toxicity to Male Fertility
(Nov. 2000)
- M3 Note for Guidance on Non-Clinical Safety Studies for the
Conduct of Human Clinical Trials for Pharmaceuticals (R2,
June 2009)
QUESTIONS?
Contact details

Name: Sally A Clode PhD, FSB, ERT

Tel: +44 (0) 1531 638240
Email: [email protected]