During this webinar, Dr Christos Roukoudis, Gynaecologist & Fertility Specialist at IVF-Life Alicante, discussed the ovarian rejuvenation method, how it works, its benefits and whether it is recommended for older patients.
Dr Roukoudis talked about the PRP and if it’s a good option for patients of advanced reproductive age, so the patients over 40. Dr Roukoudis explained that time is relative, and for all reproductive specialists and anyone who have a desire to have children, it’s the biggest obstacle. Women in general around the globe postpone childbirth until later in life, and due to this fact, they are more likely to face the problem of ovarian insufficiency by the time they are ready to have children. Moreover, the tendency of the unwanted influence of environment and social factors leads to an increase in the incidence of early menopause. As we all know, female age remains the most important and limiting factor of success in both spontaneous conception and assisted reproduction treatment, largely to a loss of ovarian follicles and the impact on the quality of the eggs.
As the graphic shows, from the puberty onwards, the process is faster, and in the time of 40 years, more or less 500 ovulations occur, and in each ovulation, 1000 oocytes are getting recruited, but in each round, only 1 gets selected, the rest get buried inside the ovary. The result is that the live birth rate, especially in women over 40 decreased significantly. Alongside the reduction in the numbers of the oocytes, we also have ageing oocytes, and those are more prone to errors in the DNA synthesis. The cell divisions result in increased aneuploidy rates, so embryos that don’t have the proper amount of chromosomes. A very important role in the decrease in the live birth rate plays other reasons, for example, alternate expression of the immune system with advanced reproductive age.
Our main goal is to enable women to become mothers with their eggs. We know the problems we are dealing with, and it relies on the number of eggs, but also the quality of the eggs. Therefore, we try to overcome this issue, and the solution that has excellent results, especially when we speak about advanced reproductive age, is egg donation. Egg donation has a very high success rate at our clinic (IVF-Life Alicante), after 3 transfers, the live birth rate is around 80%. However, this solution can cause significant psychological, financial, but also religious beliefs for some couples. There are also some legal restrictions in many countries, and for all those reasons, the possibility to restore the variable function is crucially important, and we seek a reliable way to do this.
Nowadays, there are plenty of things proposed, there are several ongoing trials that are investigated to rescue or rejuvenate the oocytes and restore fertility in women with menopause or with ovarian insufficiency. There is an option of in vitro oocyte activation, stem cell therapy, and also others exist that put some ethical point of view on topics, for example, germ cell line manipulation that is not justifiable. The bottom line is that all of those are expensive, complicated methods, and in the end, the success rate is the most important thing, and these are still very low. Therefore, an alternative is proposed, and so the PRP (Platelet-Rich Plasma), which is much cheaper and easier to apply without risks, various studies show that the results are very promising.
How are the platelets achieved? Platelets are small nuclear-cytoplasmic fragments derived from bigger cells, and although, traditionally, age is responsible for stopping bleeding from forming a blood clot, platelets attach to the wall and stop the bleeding. They also provide very important elements for tissue regeneration. Those are growth factors that are inside. There are over 15 000 proteins within the platelets, and growth factors are stored in the form of granules, and those molecules play an important role in healing tissues.
PRP stands for Platelet-Rich Plasma, it’s composed of platelets in a small volume of plasma containing a high concentration of growth factors and other cytokines. It was first used in open-heart surgery with the same mindset, which was to provide some cell regeneration. It’s now widely used in various fields. How does it work? There are several explanations, the first is that the growth factors inside activate the stem cells that are inside the ovary, and they produce new follicles. Another possible explanation is that some amount of dormant follicles are kept in the ovary, and some factors inside the platelets can promote the recruitment of those follicles. The growth factors inside get injected inside the ovary, and they increase the blood perfusion. They influence the hormones locally, and they also provide nutrients to the eggs inside the follicles.
The candidates for the PRP are women of lower ovarian reserve, and the majority are women in menopause, the perimenopause, in advanced reproductive age. Then there are also women with premature ovarian failure (POF), so women that came into menopause before the age of 40.
The PRP process means that we collect the blood, separate the platelets and then take it and are ready to inject it. We apply it inside, in the operating theatre, it is ultrasound-guided. The process is very similar to egg retrieval.
The most important thing in evaluating if treatment, especially experimental treatment, could be useful is to perform studies and see if the results are encouraging or show the opposite. The first study is from a group in Turkey, they showed the results from women who came into menopause before the age of 40. In this group, around 311 women between 24-and 40 were recruited, and those women were injected with PRP. Around 7% were able to conceive spontaneously, and around 64% developed new follicles, although they were not able to see follicles before. Around 28% had no antral follicles, so the PRP didn’t work at all.
The next study was from the same group in Turkey, presented in 2022, where they recruited around 510 women between the age range 30 and 45 who were diagnosed with a poor ovarian reserve (POR). They saw that after the PRP injection, around 4% conceived spontaneously, around 93% had some eggs, so they performed an IVF, and from that 93%, they saw that almost 312, it was 66% generated embryos and had a transfer. Around 70% of those achieved a pregnancy, and 11% had a live birth. The most important part is this 11.4%. The most important thing with those studies is to understand how many of those from 11% would achieve the pregnancy without the PRP. If the PRP was a real game-changer.
In another study, there were 83 women recruited, and those women had a low ovarian reserve. The majority of the women were over 40, and they applied PRP. 46 women received PRP, and the other 37 functioned as a control group, so they didn’t receive anything. When they compared the results, they saw that 26% versus 5% in the control group had a clinical pregnancy. Regarding a higher AMH, ovarian reserve marker, the control group with the PRP had a higher percentage, it was 24% against 5%. Keep in mind that AMH has also natural fluctuations, you can measure it twice, and you can see a difference from cycle to cycle, especially if we have an AMH at 0.1, then it could be 0.18 without doing anything. The most important thing from this study is that there was no difference in the rates of first-trimester miscarriage and live birth between those 2 groups. The impact of PRP in this study was not high.
In the next study, PRP was also performed. There was a group of around 80 patients, and among those 80 patients, 51 had an increased AMH. This study showed if we can see higher ovarian reserve markers, especially AMH, after the application of the PRP after 4 weeks. It was the first study that showed a significant increase. This study, in general, proved that PRP seems to provide some better results and can increase ovarian reserve.
Another study involved 38 women between 31 and 45, all of them had a low ovarian reserve and 2 unsuccessful attempts to receive the oocytes through IVF. They did a single PRP treatment, and the studies showed a significant improvement in the hormone levels. Some of them had a much higher increase from 0.08 to 1 nanograms, and they mentioned 10 pregnancies, and 4 were conceived naturally of 6 healthy babies delivered and born in total.
However, since PRP is still an experimental therapy, there is no standard protocol. This is very important to highlight because this fact explains the different outcomes in the various studies, there is a different time of application in those studies, a difference in the concentration of the platelets, in some studies, they inject the PRP more often, so also the technique is different, in some studies they use laparoscopy as well to apply it better, at least this is what they claim.
At IVF-Life clinic, another study is being performed, and the duration is set for 6 years. It was started in April 2021, we don’t have anything to announce so far, but in this study, we aim to demonstrate the efficiency and the safety of the intraovarian administration of the autologous conditioned serum (AAS) for the ovarian tissue regeneration.
The candidates were women between 20-50 years old and had to meet one of the criteria:
The exclusion criteria are:
The difference between this and other studies is that the administration of autologous conditioned serum (AAS) that we obtain from the platelet-rich plasma gives us only the growth factors without other cell particles. We will be able to achieve a high concentration inside of the ovary. The study will include the clinics where IVF-Life is present, so in all of the clinics. We can do a multicentric study. Then the objectives will be to improve the reserve markers and their quality to restore the menstruation cycle and the natural conception and improve the outcomes of a cycle.
The application is done at the beginning of a menstruation cycle in patients with regular cycles. First, we do priming, for example, the DHEA and CoQ10 for 6 to 8 months, then we stimulate, during the stimulation, during the egg retrieval, we apply the PRP. If there are eggs there, we recover them, fertilize and let them develop. If we can do a transfer, we do a transfer, if not, we wait for the menstruation, control the next cycles, see if we have a suitable cycle for stimulation, we don’t wait for the PRP to kick in because PRP needs at least 4 to 6 weeks at least, but it can also be after 6 months that we see a result.
We wait and look for each cycle to see if we have a good cycle for stimulation but to see an effect we need 3 months, and then there could be, for example, a second stimulation. After 20 to 40 days after the application, we measure the hormones, do a scan to see the morphology of the ovary and decide the further steps. Those could be with a positive result, we don’t wait, we start with the stimulation, and if we don’t have a positive result, we control it month per month for the next six months.
It’s very important to say that the method still remains experimental. This concerns more the patients over 40 and who come to the clinic with the desire to become pregnant. These patients usually have not only reduced or low reserve, but the quality of those oocytes is also low.
Other parameters in advanced age influence the success of a potential pregnancy, for example, the immune system. Therefore, for those couples with a very long journey behind them, with several cycles who are clinging to any potential hope of success with their own eggs, for all those reasons, it’s particularly important to empathize that with or without PRP, we still have a very low probability of success. This must be clear to the couple, we must communicate very clearly that the success of the reports presents in only a very small number of patients.
- Questions and Answers
I’m eagerly awaiting the evaluation of the results and hopefully they will allow us to draw 100% right conclusions regarding the importance of PRP and also to refine this technique even more with time. I’m pretty sure that this is the next trend.