During this event, Dr Daniel Bodri, Gynaecologist & Fertility Specialist at IVF-Life, discussed PRP and ovarian rejuvenation and whether patients with a diminished ovarian reserve can also benefit from such procedures.
During the whole process of folliculogenesis at each stage, there is a percentage of follicles that are lost during development. In the last 5 days of this process, the follicles become sensitive to female hormones and during ovarian stimulation, during the everyday practice of IVF, it’s possible to influence that in the last two weeks of the development of a follicle. This underlines the whole importance of ovarian folliculogenesis and all the factors, including growth factors and other non-hormonal factors, that intervene in this process.
How can we measure the pool of available follicles? The number of follicles peaks during fetal life at approximately 7 million, but from that moment, the decline is constant, there’s no renewal of follicles. It has been put into doubt recently, some ovarian stem cells are able to produce new eggs and follicles, but probably under normal conditions, this is not a significant number. This rapid decline starts from the late 30s until menopause, when practically no follicles remain or only approximately few thousand around the age of 50.
There are 2 methods of measuring ovarian reserve. The first one is Anti-Mullerian Hormone (AMH), the higher the level, the more potential follicles a patient has, and there’s quite a lot of variation between individuals of the same age. Another very useful tool is the ultrasound, where we can see on a 2D ultrasound some black spots, which are the tiny follicles that are there at the beginning of each menstrual cycle. We can evaluate their number, and they correlate quite well with the maximum number of eggs we can obtain during a successful ovarian stimulation.
Diminished ovarian reserve
The diminishing quantity of eggs is not the only problem of advancing female age, especially for patients over 40. Another issue is diminishing egg quality, the chances of having a live birth through IVF are constantly declining while the risk of having an early miscarriage during the first 3 months of pregnancy is increasing. This is related to this increase in abnormal eggs. The longer time period passes between the fetal life and when follicles are created until ovulation, the more likely that during the division of chromosomes, there are errors and eggs end up with an extra chromosome or a missing chromosome. Even younger patients in their 20s or early 30s have 25-30% of chromosomally abnormal non-viable eggs, but it starts to increase exponentially from the late 30s.
How can we investigate the egg quality or the quality of the resulting embryos? The only way to have precise information on the genetic makeup of an embryo is to do pre-implantation genetic testing (PGT-A). Depending on the female age, from 35 onwards, fewer and fewer chromosomally normal viable embryos are expected according to female age. For example, for patients of advanced female age above 40, approximately 20 or 5% of embryos are expected to be chromosomally normal viable embryos. Diminished ovarian reserve is very common, more than half or even two-thirds of patients nowadays fall in this category. Are there any treatments we can use to increase the number of eggs or improve egg and embryo quality? The answer is not so much. There are some hormonal interventions or additional medication that could be given, but their results are not so efficient, we might use them, but because there are no other options, so this has led to an interest in using other methods like PRP.
Plasma rich in growth factors (PRGF)
In clinical practice, the term PRGF (Plasma rich in growth factors) is routinely used. PRGF is a plasma rich in growth factors, so it is also the platelet itself, it contains granules, and these granules contain many growth factors and cytokines and other active substances. These play a role primarily in tissue regeneration if there’s an injury, but PRP products, more precisely called PRGF or plasma-rich growth factors, have been used in different fields of medicine.
How is it used? First, we need to collect a blood sample, approximately 30–36 millilitres of several cubes of blood then this blood is treated in a centrifuge, and the different parts of the blood are separated. After centrifuging with a precise protocol, red blood cells are discarded, then the next part contains different concentrations of platelets, and then it becomes denser, there’s also this intermediate layer, which contains a high amount of platelets and also leukocytes, light blood cells. Only the part containing different concentrations of platelets, the middle part, is used. It is treated with a specific protocol, the platelets need to be activated during the process, so there’s a coagulum which is formed and, the resulting end product, which could be approximately 6 millilitres, is like a yellowish plasma rich in many growth factors, much above the usual concentration that could be found in blood, this does not contain platelets or other white blood cells or other cells. This is quite safe to use without the risk of any immune reaction or anything else.
There are up to 4 groups of different patients who could benefit from this treatment. According to publications that have appeared relatively recently, 1 group are patients whose ovarian function is already severely compromised, so basically, patients who are in premenopause between 40 and 50 or even on the verge of undergoing natural menopause when the periods become irregular and FSH hormone shows the stage of this menopause is very high, maybe there are some follicles, but the chances of obtaining any variable egg is very low. Another group of patients is those with failing ovarian function, but it is premature, it happens before the age of 40. It’s approximately 1% of the female population, in most cases, this has idiopathic origin meaning that the cause is unknown, although there are some cases where there’s a genetic problem with the chromosomes or an alternating cause.
The next largest groups of patients are those who have diminished ovarian reserve. Then there are also low responders or other types of poor prognosis, for example, a few eggs or embryos of low quality, although, it is controversial whether PRP can have an effect on egg or embryo quality. These are the four main groups of patients who could potentially benefit from this treatment.
There are some contraindications, if this ovarian insufficiency is due to chromosomal issues or genetic causes or autoimmune causes this would be a contraindication of the treatment because PRGF will not change that underlying cause. Another contraindication would be where it might be difficult to do a puncture on the ovaries when the ovaries are stuck behind the uterus, or there is a history of previous pelvic surgery, where there is scar tissue which hides the ovary or if the patient is morbidly obese. In a situation where there is a suspicion of any cancerous process, whether it’s gynaecological or other. Severe endometriosis is also a contraindication, and regarding the age limit, it’s between 20 and 50 years old.
The end product can be simply injected into the ovaries, the procedure is done similarly to the egg collection during an IVF procedure. The patient is under sedation, there’s an anaesthesiologist who induces short sedation for 15 minutes, and under ultrasound guidance with the vaginal ultrasound, we can puncture the ovaries with the same needle as also used for egg collection.
This procedure could be also done if the patient undergoes IVF treatment immediately after the egg collection too. First, the eggs are retrieved, and then the remaining ovary could be also injected with this product with the aim of a successful stimulation cycle. This could be done either on a stimulated ovary or not.
What does a treatment protocol look like? At IVF Life, most of the patients fall into those groups of patients who do fertility treatment. These patients are usually in their early 40s, so they undergo ovarian stimulation, we have to think about doing 2–3 stimulations, in some cases, as many cycles as necessary to accumulate a certain number of embryos. In many cases, we do this initial injection of PRGF product during the stimulation, it’s a two-week stimulation with these injections, we retrieve some eggs and then immediately after retrieving the eggs, we infiltrate the ovaries with this product. Then we would do a follow-up period which could be 1,2 to 6 months, and if signs are encouraging, we can do a second stimulation and also do a second PRP injection at this time. The effect can last several months, so after the first PRP treatment, it’s better to repeat the stimulation cycles. If we see some positive changes on a scan or more tiny follicles appear, or the hormone levels are decreasing slightly, we can start an ovarian stimulation. If not, we can prolong the follow-up a little more.
The aim of this treatment is the improvement of ovarian reserve markers and egg quantity. Another thing is the restoration of the menstrual cycle or natural conception. Finally, potential improvement in embryological and reproductive outcomes after regenerative therapy.
Endometrial PRGF treatment
Some patients can also have a problem with their uterus. That’s another application of PRGF treatment to improve the lining. There are two types of patients, those with a thin endometrial lining, who do not develop enough lining, it becomes too thin due to different reasons, scar tissue mainly. Some patients have a good lining, but they still have many failed embryo transfers, and the embryos simply do not implant. Therefore, there are two possibilities, one is a treatment of intrauterine instillations, 1 millilitre of PRGF product is introduced into the uterine cavity, the product diffuses, and it can improve the lining. This procedure is repeated every 2 or 3 days before the actual embryo transfer.
In another method, called hysteroscopic subendometrial infiltration, a camera is introduced inside the uterine cavity and with the needle, it’s possible to infiltrate this product just below the lining, so that this effect could be much more sustained. Those two methods are often combined.
Embryo banking strategy
Additional techniques many times include also embryo banking. A patient can do 2 or 4 or even more cycles if it’s possible, the aim, depending on the patient’s age, is to accumulate 4 to 8 blastocysts, and then test those embryos through PGT-A (Pre-implantation genetic Testing) to see how many of them are actually euploid. The idea is to cultivate the embryos until day 5 or day 6 in a time-lapse incubator, then this so-called trophectoderm biopsy is performed on an embryo that has reached this stage. Chromosomes are analyzed, and we can find embryos that have normal chromosomal components. Embryos that have an extra chromosome or a missing chromosome are not valuable. Once we find such an embryo, it becomes very important to pay attention to the part of the uterus.
There are some ongoing challenges with PRP treatment, patient selection and inclusion criteria are very important. At the moment, it’s being used in many patients, there’s quite a high demand for these treatment options. However, to know more about the outcomes, stricter inclusion criteria are needed. There are some differences between different PRP products, depending on the type of the PRP product, the effect could be different. The protocols are also under development, for example, whether to use ovarian PRGF during ovarian stimulation or egg collection or outside of stimulation, whether to do it once or whether repeated ovarian puncture is necessary. Even though the technique of injection (ultrasound-guided, laparoscopic) is still being investigated, some publications where it is done through laparoscopy or coloscopy (a different type of endoscopic intervention) potentially could be a more precise method of introducing this product. There is still a lack of robust publications, however, the results are promising. Keep in mind that it is still an experimental process.