Poor ovarian reserve is one of the most challenging issues in modern reproductive medicine, particularly as more women attempt to conceive later in life. In this webinar, Dr Elena Santiago, Gynaecologist and Fertility Specialist at Vida Fertility, explored whether ovarian PRP (platelet-rich plasma) could offer new hope for women with low ovarian reserve.
Dr Santiago explained what PRP treatment involves, who may benefit from it, and how it fits into current IVF strategies, while also clearly outlining its limitations and experimental status.
The event was hosted by Barbara Scott, Chair of the Association of Reproductive Reflexologists, Founder of Seren Natural Fertility, and author of Reflexology for Fertility. Barbara is an internationally recognised expert in reproductive reflexology who advocates an integrative, patient-centred approach to fertility care.
Dr Santiago began by addressing one of the main realities of fertility treatment today: most patients struggling to conceive face age-related fertility challenges. Across Europe, the average age at which women attempt their first pregnancy continues to rise, with many starting in their early thirties.
As she explained, fertility naturally declines with age because women are born with a finite number of eggs. Over time, both the quantity and quality of these eggs decrease. This leads to:
Reduced ovarian reserve
Lower egg quality
A higher proportion of chromosomally abnormal embryos
Decreased implantation and pregnancy rates
Increased miscarriage risk
Dr Santiago highlighted that live birth rates drop significantly after the early thirties and fall sharply after 40, reaching very low levels after the mid-forties.
Low ovarian reserve affects multiple stages of IVF treatment. According to Dr Santiago, women with reduced ovarian reserve often experience:
Poor response to ovarian stimulation medication
Higher cycle cancellation rates
Fewer eggs were retrieved during egg collection
Lower fertilisation rates
Fewer embryos are suitable for transfer
As a result, some IVF cycles may end without an embryo transfer at all. Even when embryos are transferred, implantation and pregnancy rates may still be reduced, particularly as maternal age increases.
Dr Santiago outlined the current options typically offered to patients facing low ovarian reserve:
Egg and embryo donation
For many patients, egg or embryo donation offers the highest chance of success, particularly after the early forties. However, she acknowledged that this option may not be acceptable or emotionally suitable for everyone.
IVF with PGT-A
Preimplantation genetic testing for aneuploidy (PGT-A) may improve outcomes in selected cases. Its success depends on having enough embryos to test, which can be difficult for women with very low ovarian reserve.
Dual stimulation (DuoStim)
Dr Santiago explained that dual stimulation involves two ovarian stimulations within the same menstrual cycle. This approach allows clinics to collect more eggs in a shorter timeframe and may increase the number of embryos available, especially in women with poor ovarian response.
Alongside these approaches, ovarian PRP has emerged as an additional option for carefully selected patients.
PRP, also referred to as PRGF (plasma rich in growth factors), is derived from a patient’s own blood. Dr Santiago explained that platelets contain growth and tissue repair factors that play a role in healing and regeneration.
In ovarian PRP treatment, these growth factors are isolated and injected directly into the ovaries. The goal is to activate dormant or “silent” follicles that are present in early stages but do not normally respond to standard ovarian stimulation.
As she explained, standard ultrasound imaging only detects larger antral follicles. Smaller, inactive follicles remain invisible and unresponsive. PRP aims to stimulate these early-stage follicles so they may later respond to IVF stimulation.
Dr Santiago described the procedure step by step:
The patient attends the clinic between days 7 and 10 of her menstrual cycle
A blood sample is taken approximately one hour before the procedure
In the laboratory, platelets are isolated and growth factors extracted
Components that could increase clotting risk are removed
The prepared PRP solution is injected directly into each ovary under ultrasound guidance
The technique is similar to egg retrieval, but instead of aspirating follicles, the PRP solution is injected. Recovery is usually quick, and patients can resume normal activities shortly after.
Dr Santiago emphasised that PRP does not produce immediate results. The most favourable response is usually observed during the first and second menstrual cycles following the procedure.
During this time, clinicians may observe:
A modest increase in AMH levels
An increase in antral follicle count
Improved response to ovarian stimulation
This is why IVF stimulation is typically planned within the two cycles following PRP treatment.
PRP is not suitable for all patients. Dr Santiago outlined the main criteria used when considering this treatment:
AMH levels below 0.5 ng/mL
Antral follicle count of fewer than two or three follicles
Age under 45 years
Selected younger patients with premature ovarian insufficiency
She explained that in some younger patients with premature ovarian failure, even those without visible follicles or detectable AMH, PRP may help recover some ovarian activity. However, expectations must remain realistic.
According to Dr Santiago, studies have shown encouraging results in selected patients, including:
Increased number of mature eggs retrieved
Improved fertilisation rates
Higher implantation and pregnancy rates compared to similar age groups with low ovarian reserve
However, she stressed that results vary significantly between patients and success cannot be guaranteed.
Dr Santiago was clear that ovarian PRP is still considered an experimental treatment. Although it has been used in fertility clinics for several years, there is not yet enough conclusive scientific evidence to confirm its effectiveness for all patients.
She emphasised that:
PRP does not work for everyone
Outcomes depend on age, ovarian quality, and individual biology
It should only be offered after careful patient selection and counselling
As she stated, “we are not sure it is always going to work,” and patients should be fully informed before proceeding.
In conclusion, Dr Santiago explained that ovarian PRP may offer an additional option for women with poor ovarian reserve, particularly those under 45 or younger patients with premature ovarian insufficiency. While early results are promising, PRP should be viewed as part of a broader, individualised fertility strategy rather than a guaranteed solution.
Careful evaluation, realistic expectations, and personalised treatment planning remain essential when addressing low ovarian reserve and IVF success.
It’s more of a combination. I mean, yes, PGT-A screening right now is recommended from 38 to 40 years onwards. But then you have to individualise, obviously, for each patient. I do believe that from—I’m not going to say 45—but from 46 onwards, it’s so difficult to finally achieve blastocysts of good quality, and that afterwards those embryos are really good chromosomally. It’s difficult to tell patients, but in the majority of cases, I don’t think it’s worth it. I believe at that point, it’s better if we go ahead directly with egg donation treatment.
As I said, we need to individualise. If you have a case where ovarian reserve is really good for their age and they’ve never tried a treatment before, sometimes they need to do at least one ovarian stimulation to see what happens before going ahead with egg donation, even if they know that maybe it’s not going to work. They need that. But if you already have a patient who has gone through several IVF treatments without success, and you already see that the quality is not good, then perhaps, for that patient, even younger, it’s better to go directly with egg donation.
Correct. I forgot to tell you that we need to monitor AMH levels and also antral follicle count before we start the ovarian stimulation. And sometimes, even if we are doing that in the next cycle after the PRP infusion and we see that more or less the parameters are exactly the same as before, we even sometimes wait for the second cycle, because maybe it will be better for that patient.
You can’t say 100%, but it’s true that if the situation is the same, maybe it could be better in the second month.
I mean, a natural pregnancy can always happen. We never say 0%. The problem here is that you’re going to optimise the results much more by doing stimulation. If before PRP you’re able to get one or two follicles, and after PRP maybe one or two more, then no—the more you get, the better the options you’ll have. Because one egg can make the difference. Naturally, there’s usually only one egg selected, only one egg ovulated, and therefore, we only have that one chance. If we do stimulation and have around three eggs, for example, then we have several chances, not just one, like naturally.
Absolutely. I mean, with egg donation, right now, for example, at our clinic, we give guarantees of achieving blastocysts of good quality. I always explain to patients that this is biology—and even with a donor, sometimes it doesn’t work—but the clinic is going to give you the guarantee of achieving at least two, or at least three (whatever you decide), blastocysts of good quality to have several attempts. With your own eggs, I’m not able to give you that guarantee. Maybe you respond to the treatment and we are able to retrieve some eggs, but I’m not sure if those eggs are going to be fertilised. It depends on the quality. For sure, we are not able to give any guarantee of achieving embryos of good quality, because sometimes, due to egg quality, the embryos stop naturally. That’s the most difficult part, apart from later having good chromosomal embryos if the woman is older than 40.
It’s so important. I find it so important to inform patients properly. Give them their options. I mean, I’m not close to one option or the other. I’m advising you the best, obviously, but I’m giving you all the possible options so that you can finally decide, based on your ideas, what you want. And as I said, maybe you know that the IVF option is going to give you less than a 3% pregnancy rate, but you need to go through that before doing other treatments that can obviously increase the chances.
Well, we are a little bit at the limit. We could indeed try PRP, but even with your AMH value right now, it is not so bad.
Knowing that you’ve had embryos before while going through IVF, we can see the option of doing, first of all, PRP and then the dual stim IVF procedure with the PGT-A testing.
That, for sure, I find very, very needed in your case, so that we only do a transfer if we really achieve at least 1 healthy embryo. Therefore, your chances are going to be really, really high. The difficult part is getting there, but if we do get there, afterwards the pregnancy rate could be around 70%.
Endometrial PRP — it depends on how you use it. There are two options right now.
The one that is mostly done, I believe, in all clinics is to do a PRP infusion — normally it’s around 3 infusions, several days before the transfer.
In that case, we only leave the PRP inside the uterus, and therefore, the effect is going to be for that transfer. If you need other transfers, you need to do the PRP infusion again several days before.
Second option, which is quite new, and good that you’ve asked this question, because I also wanted to introduce this second option —
is to do a subendometrial PRP infusion. This is different because we go inside the subcutaneous tissue of the endometrium. Maybe it’s more difficult to do the procedure because it’s not just like an infusion, such as when we do the transfer.
It’s different because we need to go through a hysteroscopy — meaning introducing a camera inside the uterus vaginally — and in that same hysteroscopy we go with a very small needle, doing small injections through all the endometrial tissue. This is different because the effect normally is going to last for around 6 months. Here we are trying to see the effect of this, but it’s recommended when we have loads of problems to get a good endometrial size. It depends on each case, obviously, but it’s quite a new procedure.
Yes, it’s different from the first option. In the second option of subendometrial PRP, you are not going to do the transfer right away. You are going to try the transfer normally, at least in the next cycle. It’s true that if you don’t get pregnant, the effect is going to last longer, and therefore, you can try other transfers in the next cycles with that effect still.
As I said, the limit should be around 45 years for PRP treatment, and I believe as well for IVF treatments.
You indeed have a super good ovarian reserve for your age. It’s very good that you still have such regular cycles and ovulation, even if it occurs a little bit earlier than normal. That is still normal.
However, I do believe that at 52 years old, the quality of the eggs is not going to be enough. I can never say impossible, but if you do achieve eggs, it’s really difficult to achieve embryos, and the most difficult part is having chromosomally normal embryos. In this case, I don’t believe that either PRP or IVF is are good option, unfortunately.
It is very difficult. It’s true that it also depends on the law of each country. As you’re saying, stimulation is not an option by law.
Therefore, natural cycles sometimes do work and may even be a better option if you know that stimulation won’t give a better response than one single follicle.
You didn’t mention your age, but, indeed, PGT-A testing is not 100% reliable—it’s around 90%. Depending on age, if we know you’re going to have only one egg and one embryo each time, and you are between 40 and 42 years old, maybe a fresh embryo transfer is an option instead of doing a biopsy. I agree with that.
I do believe that from 43 or 44 years onward, it’s always going to be better to biopsy the embryo. A blastocyst-stage, good-quality embryo is really strong, and you’re not harming its chances of implanting by doing the biopsy. On the other hand, you gain very important information—90% reliability. If the embryo is healthy, implantation rates can increase to around 70%, and the risk of miscarriage in the first trimester is much lower. If you transfer an embryo without that information from age 43 or 44 onwards, then you never know why it doesn’t implant or why a miscarriage occurs.
Of course, opinions may vary, but depending on age, we need to give different options and finally decide what to do.
Yes, absolutely. These are different concepts. PRP treatment is to try to increase the response of women with very low ovarian reserve.
As we know, with more response, we can get more eggs and therefore more chances of achieving embryos.
The greater the number of embryos for PGT-A treatment, the better, because we can have more to select from and more chances of finding a good one.
The chances of each egg are going to be the same, but it’s pure statistics. If you have, for example, a normal embryo rate of 3%, and with one single stimulation without PRP treatment, you are able to produce two embryos, you only have that 3% rate of finding a good one. If before the treatment, you add PRP and do a dual stim to accumulate embryos, and with that combination, you achieve four to five embryos, obviously within that larger number, you’re going to have more possibilities of finding the good embryo, the healthier one. That’s the aim of all these treatments.
Correct. That’s absolutely correct. PRP is not helping with ovarian quality, with egg quality. It’s only helping with quantity by increasing AMH levels and follicle count.
In your case, I don’t think it’s the best option to go ahead with PRP treatment for the ovaries. Another thing is maybe for the endometrium, as we’ve just talked about, to increase implantation rates. That could be the case.
Because of age, I’m sorry, but I don’t believe that IVF with your own eggs is the correct treatment. Even if you still have more or less good ovarian reserve, the quality is really poor, as we said, from 45 years onwards. I don’t believe IVF is the option, even if you’ve never done treatments before.
Then, regarding the fibroids, it’s very important to see that they don’t affect the cavity or the endometrium, where the embryo needs to do the implantation and grow. Some fibroids, if they are in the outside parts of the uterus and don’t affect the cavity, it’s fine. In the majority of cases, we can go through a treatment and a pregnancy without needing to touch those fibroids, only control their growth over time.
If they do touch the cavity or affect the cavity in some way, then it will be better to correct that with surgery—either with a hysteroscopy internally through the uterus or sometimes an abdominal procedure to get out those fibroids. It depends on each case.
