In this webinar, Dr Harry Karpouzis, Scientific Director and Founder of Pelargos IVF shared his expertise on how PRP and ovarian rejuvenation could help you in your fertility journey. He discussed its effectiveness, treatment benefits, current studies and research, as well as age impact and optimal timing
PRP is a well-known treatment and has been used across many specialities for a long time. It was first used in 1987 in open-heart surgery and is now widely utilized in cosmetics, plastic surgery, orthopaedics, ophthalmology, neurosurgery, and many other fields.
What is PRP? PRP stands for platelet-rich plasma. Autologous PRP means it is derived from the patient’s own blood. We draw about 20 to 60 mL of blood from the patient, place it into specialized machines, and centrifuge it. By applying mechanical pressure through centrifugation, we separate the plasma, platelets, and red blood cells. The result is a solution of platelet-rich plasma, usually about 2 to 4 mL or more, which can then be injected into the ovaries. This procedure is very similar to egg collection, performed under ultrasound guidance with minimal risks.
The purpose of PRP treatment is to stimulate the production of growth factors and cytokines in the ovarian cells. The theory behind it is that this process can rejuvenate the ovaries, potentially leading to increased egg production or the return of menstrual periods.
In Athens, where Dr Karpouzis’ practice is located, they also perform PL PRP, which is a stronger version of PRP. The difference lies in the process; in PL PRP, the platelets are broken down in the lab, and the solution injected into the ovaries already contains activated growth factors and cytokines. This version is considered to have 10 to 15 times more growth factors and cytokines.
It is important to note that these treatments are experimental and do not have conclusive evidence, especially in the context of fertility. I want to be clear about this because you are investing time and money in these treatments, so you need all the information before deciding to proceed with something that is still experimental.
PRP can be considered for women of advanced age with a reduced number of eggs or declining egg quality, often associated with ageing. It may also be an option for women with premature ovarian failure, those in perimenopause or menopause who wish to restore their menstrual cycles, poor responders, or those with low AMH and high FSH levels. It is often the last treatment option before considering egg donation when previous attempts with one’s own eggs have failed.
PRP is also used for gynaecological reasons to restore the menstrual cycle, improve hormonal profiles, avoid hormone replacement therapies (HRT), alleviate perimenopausal and menopausal symptoms like hot flashes and night sweats, and increase sexual drive.
How do we know if PRP has been effective? It’s a challenging question because PRP takes time to work. It may show results in 1 to 6 months. If it hasn’t worked within the first 3 months, the likelihood of it working later is less than 10%. A common question is whether a second treatment can be done. The answer is that there is no conclusive evidence to support or reject this, so it depends on individual cases. If there is a slight improvement after the first treatment, a second treatment might be considered, but we would hesitate to perform it more than twice.
To measure results, we monitor AMH, FSH, estradiol, LH, and antral follicle count before and after the treatment. These levels are checked monthly for several months following the treatment. If there is significant improvement, it is advisable to proceed with ovarian stimulation promptly, as the effects may not be permanent.
Hormonal tests are necessary, but it would also be good to check your karyotype, especially if a woman suffers from premature ovarian failure because if someone has a chromosomal issue, PRP will not work. A full blood count and a coagulation check are needed. An ultrasound is essential to check the antral follicle count and rule out large cysts, which can cause problems when PRP is injected. It’s also important to rule out conditions like pelvic infections and cancers because injecting PRP into ovaries with these conditions might spread them.
Does it help with egg quality? Data shows that there is an improvement in the hormonal profile. For example, women with higher FSH levels, more than 25, are usually avoided for stimulation because they have a very high risk of cancellation. After PRP, they might see a drop in FSH and become eligible for stimulation. An improvement in the antral follicle count has also been shown. If someone has 3 follicles, you cannot get more than 3 eggs in 1 round of stimulation. However, when you do PRP and see an increase in the antral follicle count, which is often observed in the majority of patients, you might get a couple more eggs. The more eggs you get, the higher the chances of statistically getting 1 chromosomally normal egg.
For older women, a large number of eggs is necessary to have a good chance of obtaining a chromosomally normal egg and embryo. After the age of 38, there is a drop in egg quality, which means an increase in chromosomal abnormalities. PRP will not change the chromosomes. PRP cannot be associated with a quality improvement, but most studies show an improvement in the number of eggs retrieved, thereby slightly increasing the statistics.
This is a very simple procedure. The risks are the same as with egg collection, with minimal risks of infection, bleeding, or injury to the bowels and vessels, which are very unlikely. It needs to be done by an experienced doctor because usually, the ovaries in women who want PRP are smaller, so you need to locate them easily. There is almost 0 risk of allergies and rejection because we are talking about autologous PRP, which means using our own blood. There is also 0 risk of infection transmission. There are some minor anaesthetic risks and blood clot risks. What about long-term risks?
All the studies have not shown any long-term risks, nor have they been associated with cancers or anything like that. However, when you undergo these procedures, you need to keep in mind that there are still not enough studies and long-term effects studies are needed as well. When you do these treatments, you sign a consent regarding that.
Many studies, including various ones, have shown improvement in the hormonal profile, the number of eggs, and the number of chromosomally normal embryos (euploid embryos) achieved in women undergoing PRP. More embryos, better AMH, better FSH, and better antral follicular counts—these are the best results that exist, according to these studies. One big meta-analysis (which means many small studies combined) with 793 participants showed a clinical pregnancy rate of 25.4% and a live birth rate of 16.6%. This study also confirms the improvement in the hormonal profile.
The question, however, is whether it is clearly associated with an improvement in pregnancy rates. After these treatments, you do see live births and sometimes clinical pregnancies, but it is very difficult to say if it is indeed from the PRP, the protocol applied, or if someone had become pregnant one way or another without the PRP. It is challenging to get clear answers on whether it is associated with an improvement in pregnancy rates, especially in older women, where it seems that it is not associated with improved pregnancy rates or live births. However, all the trends and reports suggest it might be associated with an improvement in the number of eggs retrieved.
From the data collected, involving women ranging from 26 to 54 years old, with 30% using PRP and 70% using PL PRP, an improvement in AMH, FSH, and estradiol in 70% of the patients has been observed. AMH increased by 37%, and 50% of the women saw a reduction in FSH. The improvements are more significant in women under 40 than in those over 40. Additionally, with PL PRP, there have been slightly better improvements in AMH, FSH, and other rates. 30% of women close to menopause resumed their periods, with a 15% conception rate. However, these statistics cannot prove a significant advantage in pregnancy rates.
We can say that, at least in our data, there is an improvement in the hormonal profile and the number of eggs someone might retrieve.
When should the treatment be done and at which stage of the cycle? Anytime, if someone doesn’t have a cycle. As Dr Karpouzis mentioned, they prefer to do it at the beginning of the cycle, like the 3rd to 8th day, in women with cycles to avoid a large ovulation follicle or cysts. If someone doesn’t have a regular cycle, is it scheduled with hormones? The answer is better not. If someone decides to go with PRP, it is better to measure the hormone levels before and after. If it is done while someone is on contraceptive pills or anything similar, then the results are not going to be accurate.
Some follicles cannot be seen, they are called primordial follicles. These follicles eventually develop into primary, secondary, and antral follicles, which are the ones that are seen at the beginning of the cycle. These mature into antral follicles. From primordial follicles to antral follicles, there is a local growth factor that plays a role. Then, from antral follicles to mature follicles, FSH and LH are involved, along with other hormones like AMH. Growth factors like TNF, interleukin-1, TGF, insulin growth factor, and others help in the development of these follicles and in preventing atresia (the degeneration) of the follicles, aiding in getting more follicles.
PRP is rich in growth factors produced by the platelets after activation, either outside the body or inside the ovary. When PL PRP is performed, for example, thanks to freezing and thawing the platelets are breaking producing platelet-rich plasma and helping create more follicles. These factors also help in creating vessels, rejuvenating the ovary, and making it more viable for egg production. When they are injected, a minor injury to the ovaries is caused, leading to local inflammation, which triggers a cascade of growth factors and cytokines that also help. PRP has also been shown to work on the immune system, with studies suggesting it might even help the hypothalamus and pituitary glands in hormone production.
Stem cells are not yet a proven treatment for fertility. Stem cell treatment involves extracting adipose (also known as body fat or simply fat) tissue from the abdomen, as it has been shown that the abdomen provides the best fat tissue rich in stem cells. This procedure can be done with a plastic surgeon, producing something called SVF (stromal vascular fraction). This can be done either mechanically, with centrifugation, with enzymes, or with cultures. This process produces stem cells, it’s possible to obtain about 2 to 6 million stem cells from 1 ml of fat aspirated from the abdomen. Then, it’s possible to inject this solution, often with PRP, into the ovaries.
These stem cells can either differentiate into germ cells or activate endogenous cells inside the ovary to produce more stem cells, create vessels, activate ovarian stem cells, and stop the destruction of follicles. The local trauma or injury is crucial because it causes local inflammation, which is why, even with a placebo (no actual treatment), the injury alone might improve things in some studies.
It’s important to know that stem cells are not proven for fertility. Therefore, you sign a consent form acknowledging that you are undergoing an experimental treatment. There is no conclusive evidence to associate it with an improvement in egg quality or pregnancy rates, especially in women over 44. However, the trend in younger women is there, though it’s not statistically significant yet. There is still not enough data to show improvement in hormone levels and antral follicle counts, and sometimes, a few extra eggs might make a difference if you are lucky.
There are no long-term studies so far, and you need to be aware of that. There is a trend towards showing restoration of the cycle in menopausal patients. All the reports so far show that it is safe, but there is no long-term data to confirm this. A consent form needs to be signed, acknowledging that this treatment is experimental. Since it is not clearly associated with improved pregnancy rates, you need to know that it can be used for gynaecological reasons, with the hope that more studies will eventually confirm definite fertility improvement, especially regarding pregnancy rates, because it does help with antral follicle count and the hormonal profile.
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There’s not much you can do to improve the blood quality before PRP. We take the blood and centrifuge it, using techniques that may involve either mechanical or chemical activation of the platelets. Our job is to create as many growth factors, cytokines, and platelets as possible to inject into the ovaries. It’s not something you can improve yourself. It is better to avoid aspirin before the treatment, but the percentage of cells we get doesn’t depend on actions you can take.
Some menopausal women want to undergo PRP treatment. To be clear, the chances of getting pregnant with their eggs during menopause are very low. We have seen pregnancy and live birth in a menopausal woman who had not had a period for 11 months, but I cannot say this was definitely due to PRP. PRP can restore periods in some women, but it doesn’t work for all. If FSH levels drop to a point where stimulation is possible, you might have a chance for stimulation. However, getting pregnant and having a live birth from that stage is a long process.
In Greece, the upper age limit for treatment is 54. At our clinic, we don’t believe there’s enough evidence to treat women over 50 with their own eggs, even with PRP. The main issue at this age is chromosomal abnormalities in the eggs. So, while PRP might offer one more chance, the chances of success are still very low. I don’t think it’s worth pursuing treatments at this stage, as I haven’t seen a live birth in women over 50 using their own eggs, with or without PRP, in many years.
Keep in mind that there’s no clear answer because there’s no conclusive evidence on this. We generally don’t want to do more than two PRP treatments if there hasn’t been any improvement. If the first PRP treatment doesn’t work, we might consider doing a second PRP or PL PRP. However, if after giving it time there’s still no improvement, we don’t recommend continuing with more PRP treatments. The policy in our clinic is to try PRP, observe for improvement, and proceed with stimulation if it works. If not, it’s acceptable to move on to another treatment, but I can’t provide a definitive scientific answer due to the lack of data.
There are many issues here. It’s not just the sperm; adenomyosis and endometriosis also play significant roles. Endometriosis affects not only the quality of the eggs but also implantation. So, many factors could be contributing to your difficulty in getting pregnant. I cannot say that the eggs are the only issue.
If we are talking about low ovarian reserve, which is common with endometriosis grade three, it’s important to note that you are in a good age group, which is positive. However, as I mentioned in my presentation, I can’t say with certainty that PRP helps with quality; it might help with quantity, but that’s not guaranteed.
Besides endometriosis grade 3, there are other factors to consider, like the potential difficulty of PRP injections due to scar tissue, which could make it tricky to reach the ovaries. There are risks involved, especially when aiming to retrieve just a couple more eggs. If it’s possible to access it easy, you can try PRP since you are young, and we have observed that PRP works better in women under 40. However, I cannot say definitively that the quality of the eggs is the only reason you’re not getting pregnant, as all these factors you’ve mentioned are linked to subfertility. PRP is an option if you want to continue trying with your own eggs, as it might yield a couple more eggs, and sometimes, you only need 1 chromosomally normal embryo to succeed.
Depending on the type of PRP, you will need either one day or two to three days. For PL PRP, we need to create the sample, which takes some time, so you will need two to three days. For regular PRP, you will need one day. However, you need to ensure you have already done infection tests in the last month. We need to make sure you are infection-free before the procedure because we put all the samples into centrifugation machines. You can either do the infection test the previous day and then do the PRP the next, or bring the results and do the PRP on the same day. If you want, you can travel later on the same day or the next day.
We advise this depending on the age because you need to balance things. If someone is older, you cannot wait too long because you are getting older. Generally, if we see improvement, it happens within the first three months. Significant improvements are often seen in the first or second month, sometimes the third. If there is no improvement in the first three months, we have seen improvement even after that, but in a smaller percentage. Monthly, after each period, it would be a good idea to be ready—have the medication available, have your doctor prepare your protocol, and check AMH, FSH, and antral follicular count.
If there is a significant improvement, go ahead with the stimulation. Don’t wait for the next month. If you have enough follicles, you might not get all the eggs in one go, so you might need to do multiple stimulations. If there is no improvement, wait for another month, but if there is improvement, go ahead, get some eggs, and then repeat the next month.
Most significant improvement happens within one to three months post-PRP. There is no definitive scientific answer to how many PRP procedures are recommended. I could say three, four, or five, but when you are doing an experimental treatment, I cannot advise repeating it too many times. We usually stop at two procedures—either PRP and PL PRP, or 2 PL PRPs. As for how often you can do PRP, we have already discussed that. Regarding how many egg retrievals one can do after just one PRP treatment, if there is improvement in the hormonal profile and enough follicles, go ahead and repeat the egg retrieval. The more egg collections, the more eggs you will get.
To put it simply, PL PRP involves a more intensive process where the sample is put through freezing and heating cycles, which breaks the platelets and activates growth factors and cytokines. These are then injected into the ovaries. In regular PRP, the sample is centrifuged 2 times to create a platelet-rich sample, which is injected into the ovaries, where the activation happens inside. That’s the difference in simple terms.
First, I’m not sure if this is picograms per millilitre or nanograms per millilitre. If it is picograms per millilitre, it’s a low AMH. If it is nanograms per millilitre, it’s a high AMH, and I don’t think you need PRP. Please clarify this because it’s very important—whether the measurement is in picograms per millilitre or nanograms per millilitre—so I can answer properly.
Yes, for any treatment, the age limit is 54—for both egg donation and IVF with your own eggs. However, at our clinic, we have decided not to offer treatments with own eggs for women near this age limit because the chances of success are so low. But by law, the maximum age is 54. This was changed recently; it used to be less than 50, then 52, and now it’s 54.
