The value of platelet-rich plasma in women with previous implantation failure: a systematic review and meta-analysis

Comparative efficacy of intrauterine infusion treatments for recurrent implantation failure: a network meta-analysis of randomized controlled trials

OBJECTIVE

Recurrent implantation failure (RIF) is a significant challenge in assisted reproductive technology (ART), affecting many women undergoing in vitro fertilization (IVF). This study aims to compare the efficacy of various intrauterine infusion treatments, including granulocyte colony-stimulating factor (G-CSF), platelet-rich plasma (PRP), human chorionic gonadotropin (HCG), and peripheral blood mononuclear cells (PBMCs), in improving clinical pregnancy rate (CPR), live birth rate (LBR), and miscarriage rate (MR) in women with RIF.

METHODS

A comprehensive search was conducted in multiple databases, including Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Web of Science, and China National Knowledge Internet (CNKI), to identify randomized controlled trials (RCTs) evaluating the efficacy of intrauterine infusion treatments for RIF. Data extraction and quality assessment were performed independently by two reviewers. Network meta-analysis was conducted using a random-effects model to compare the outcomes of different treatments.

RESULTS

A total of 25 RCTs involving 3035 patients were included in the network meta-analysis. The treatments involved G-CSF, PRP, HCG, PBMCs, placebo, and blank control. The results of the network meta-analysis for CPR and LBR were statistically significant among treatments, but there was no statistical significance in MR. The surface under cumulative ranking curve (SUCRA) ranking of CPR and LBR showed that intrauterine infusion treatments of G-CSF, PRP, HCG, and PBMCs were much better than placebo and blank. The SUCRA values of CPR were ranked probabilistically from high to low as follows: PRP (84.5%) > PBMCs (76.5%) > G-CSF (65.7%) > HCG (52.5%) > placebo (20.8%) > blank (0.1%). The SUCRA values of LBR were ranked probabilistically from high to low as follows: PRP (81.4%) > PBMCs (64.6%) > G-CSF (58.0%) > HCG (48.7%) > placebo (42.4%) > blank (4.9%).

CONCLUSION

All these findings confirmed that intrauterine infusions of PRP and PBMCs significantly improve pregnancy outcomes in women with RIF. PRP emerged as the most effective treatment. However, to establish the most effective approach for managing patients with RIF, future research should prioritize direct and robust comparisons between PRP and other therapeutic strategies, ensuring a comprehensive evaluation of their relative efficacy.

Transcriptomic landscape of cumulus cells from patients <38 years old with a history of poor ovarian response (POR) treated with platelet-rich plasma (PRP)

Intraovarian injection of autologous platelet-rich plasma (PRP) has recently been investigated as a potential treatment for patients with diminished ovarian reserve. In the current study, differential gene expression in cumulus cells obtained from patients treated with PRP was compared to controls. RNA sequencing libraries were constructed from the cumulus cells, and differential expression analysis was performed with a false discovery rate threshold of p-value ≤0.05 and Log2 fold change ≥0.584. RNA sequencing of cumulus cells revealed significant differences in gene expression when comparing those treated with PRP and resulted in a live birth (n = 5) to controls with live birth (n = 5), or to controls with failed implantation (n = 5). Similarly, when all samples treated with PRP (those that resulted in live birth or arrested embryos (n = 10)) were compared to all samples from controls (those that resulted in live birth, no pregnancy, or arrested embryos (n = 13)), gene expression was significantly different. Several pathways were consistently affected by PRP treatment through multiple comparisons, including carbohydrate metabolism, cell death and survival, cell growth and proliferation, and cell-to-cell signaling, all of which have been implicated in human causes of infertility.

Advances in human umbilical cord mesenchymal stem cells-derived extracellular vesicles and biomaterial assemblies for endometrial injury treatment

Endometrial injury caused by repeated uterine procedures, infections, inflammation, or uterine artery dysfunction can deplete endometrial stem/progenitor cells and impair regeneration, thereby diminishing endometrial receptivity and evidently lowering the live birth, clinical pregnancy, and embryo implantation rates. Currently, safe and effective clinical treatment methods or gene-targeted therapies are unavailable, especially for severe endometrial injury. Umbilical cord mesenchymal stem cells and their extracellular vesicles are characterized by their simple collection, rapid proliferation, low immunogenicity, and tumorigenicity, along with their involvement in regulating angiogenesis, immune response, cell apoptosis and proliferation, inflammatory response, and fibrosis, Therefore, these cells and vesicles hold broad potential for application in endometrial repair. This article reviewed recent research on human umbilical cord mesenchymal stem cells as well as their extracellular vesicles in repairing endometrial injury.

Interventions for recurrent embryo implantation failure: An umbrella review

BACKGROUND

Recurrent implantation failure (RIF) has a multifactorial etiology. An umbrella review was undertaken to evaluate the multiple proposed interventions.

OBJECTIVES

To summarize and assess the strength of evidence of interventions for RIF from published systematic reviews (SR) of randomized clinical trials (RCTs).

SEARCH STRATEGY

After prospective registration (PROSPERO CRD42023414255), a systematic search was conducted in the Cochrane Library, Scopus and Medline from inception until March 2024.

SELECTION CRITERIA

SRs of RCTs, with or without meta-analyses (MA), were included if they reported clinical pregnancy rates (CPR) or live birth rates (LBR).

DATA COLLECTION AND ANALYSIS

The methodological quality of the included SRs was appraised independently in duplicate using the AMSTAR 2 tool. For each intervention, the MAs of RCTs with statistically significant improvements were counted as a percentage of the total assessing the strength of evidence using the GRADE system.

MAIN RESULTS

A total of 47 SRs were included: 32 reviews covered immunomodulatory interventions, 10 (68 RCTs) covered uterine and endometrial interventions, one covered antibiotics, and four (69 RCTs) addressed mixed approaches, including laboratory interventions. AMSTAR 2 appraised 41 (88%) SRs as critically low or low, and 6 (12%) as moderate or high in quality. The SRs often had a level of overlap of RCTs (median 33.3%), inconsistent definitions of RIF, and varied comparisons for the interventions. Considering the significant meta-analytic evidence of high-moderate GRADE strength: Granulocyte colony-stimulating factor (G-CSF) showed improvement in CPR in 9/13 (69.2%) MAs and LBR in 1/7 (14%); intralipid infusion showed improvement in CPR in 4/6 (57.14%) MAs and LBR in 3/4 (75%); peripheral blood mononuclear cells (PBMC) showed improvement in CPR in 4/8 (50%) MAs and LBR 3/5 (60%); platelet-rich plasma (PRP) intervention showed improvement in CPR in 6/10 (60%) MAs and LBR in 1/5 (20%); human chorionic gonadotropins showed improvement in CPR in 3/3 (100%) MAs; growth hormone showed improvement in CPR in 1/1 (100%) MA; low molecular weight heparin showed improvement in CPR in 1/1 (100%) MAs and LBR in 1/2 (50%); hysteroscopy showed improvement in CPR in 1/2 (50%) MAs; and, intentional endometrial injury showed improvement in CPR in 3/4 (75%) MAs and LBR in 2/3 (66.66%).

CONCLUSIONS

Evidence syntheses of RCTs evaluating interventions for RIF suggest a consistent direction, with high to moderate strength, indicating that immunomodulatory treatments, including G-CSF, PBMC, PRP, intralipid infusion, and intentional endometrial injury are likely to be effective. However, this conclusion should be interpreted with caution due to the generally low methodological quality of the included studies and the clinical heterogeneity observed in most SRs.

Intrauterine infusion of autologous platelet rich plasma can be an efficient treatment for patients with unexplained recurrent implantation failure

The studies posits that there is not sufficient evidence to support the use of intrauterine platelet-rich plasma (PRP) infusion in patients with recurrent implantation failure (RIF). This study aims to investigate the effects of infusion of PRP on patients with unexplained-RIF in fresh and frozen embryo transfer (ET) cycles. A total of 80 participants were included in this study. The participants were randomly assigned to one of two groups with and without PRP infusion. Each of the PRP and control groups were also divided into fresh and frozen ET subgroups. ET outcomes were compared between groups. Clinical pregnancy rate was significantly higher in Frozen ET in PRP group than other subgroups (p < 0.0001). Miscarriage rate were significantly lower in PRP group than control group. Pregnancy complications and preterm labor were significantly higher in PRP group than control group (p < 0.0001). Live birth and healthy baby rate were significantly higher in PRP group than control group (p < 0.0001). The intrauterine infusion of 0.8-1 ml of PRP 48 h before blastocyst ET at fresh and frozen cycles can be an efficient treatment option for u-RIF patients. Also, results indicated that the clinical pregnancy rate was equal to the live birth rate at fresh ET cycles, whereas the live birth rate was lower than the clinical pregnancy rate at frozen ET cycles. Therefore, considering the superiority of fresh cycles over freeze cycles, the infusion of PRP into the uterus of patients with RIF is recommended to be done at fresh ET cycles.Trial registration: NCT, NCT03996837. Registered 25/06/2019. Retrospectively registered, http://www.clinicaltrial.gov/ NCT03996837.

Efficacy of intrauterine autologous blood cell derivatives in enhancing endometrial thickness and IVF outcomes for women with recurrent implantation failure: a retrospective cohort study

PURPOSE

The purpose of this study was to determine the effects of intrauterine infusion of autologous blood cell derivative (ABCD) on endometrial thickness and pregnancy outcomes in a group of patients who underwent IVF with recurrent implantation failure (RIF) and who had either a normal endometrium or thin endometrium.

METHODS

This retrospective study included 63 patients who experienced RIF at the Department of Reproductive Medicine and Surgery, KMC, Manipal, between January 2021 and March 2024 and who received three doses of intrauterine ABCD infusion to prepare the endometrium for frozen embryo transfer (FET).

RESULTS

We enrolled 63 RIF patients, 30 with a normal endometrium (NEM) and 33 with a thin endometrium (TEM). The endometrial thickness (EMT) significantly increased across all the groups. After 3 cycles of intrauterine ABCD infusion, the mean increases in EMT in the NEM and TEM groups were 0.77 mm and 1.36 mm, respectively, which were statistically significant. Among the 62 completed FET cycles, 40.3% were positive for beta-hCG. The clinical pregnancy rate was 33.8% (40% in the NEM group, 28.1% in the TEM group), and the live birth rate was 24.2% (30% in the NEM group, 18.8% in the TEM group). A total of 9.7% of pregnancies had spontaneous miscarriages. Moreover, the EMT did not differ between the pregnant and nonpregnant groups.

CONCLUSION

Intrauterine ABCD infusion improves the pregnancy outcomes of patients with RIF, regardless of the EMT. The results of this study revealed that endometrial receptivity improved significantly along with the EMT.

Effect of Platelet-Rich Plasma (PRP) in Combination with Endometrial Scratching for Patients Undergoing Assisted Reproductive Technology Treatment

Endometrium scratching is a process of intentionally injuring the endometrium, and after scratching the endometrium, platelet-rich plasma (PRP) is inserted into the endometrial wall to improve pregnancy outcome. This case report revolves around a 33-year-old woman and her 38-year-old husband, who have been married for 3 years and were seeking treatment for their secondary infertility. The female had a history of hypothyroidism, and after the investigation, she was diagnosed with hyperprolactinemia. She also had a history of failure in vitro fertilization (IVF) cycles and two recurrent miscarriages upon investigation. The husband was found to have asthanozoospermia. After diagnosis of the female, we started treatment of cabergoline for hyperprolactinemia, a history of unsuccessful IVF cycles, and two recurrent miscarriages upon investigation. After the treatment of hyperprolactinemia in our clinic, we scheduled ovum pick-up and started the stimulation and performed intra-cytoplasmic sperm injection. After 1 month, we scheduled embryo transfer. On day 1, the progesterone scratched the endometrium wall and loaded the PRP to enhance the endometrial wall, and after an interval of 14 days, we checked the β-hCG level in the blood, and the result was positive, that is, the level was 1020 mIU/mL. The successful result of endometrial scratching with PRP improves pregnancy outcomes.

Not all platelet-rich plasma are created equal

PURPOSE OF REVIEW

This review aims to elucidate potential variations in clinical outcomes resulting from the use of different types of platelet-rich plasma (PRPs) in reproductive medicine. It seeks to explore the reasons behind the diverse results reported in various studies and assess the general features distinguishing different PRP formulations.

RECENT FINDINGS

PRPs have found applications across diverse medical fields, generating controversy due to the variability in outcomes. The field of reproductive medicine, despite its limited published studies, is encountering a similar challenge as it integrates these treatments.

SUMMARY

The multitude of PRP product brands in the market, coupled with 'home-made' PRPs, poses a significant barrier to establishing a common protocol for the preparation of standardized PRP products. This impediment hinders widespread adoption by clinicians, particularly in endometrial or ovarian treatments. Drawing from evidence in other medical disciplines, this review endeavors to compile essential characteristics that PRPs must possess, aiming to mitigate the impact of variables affecting results in forthcoming studies.

The value of intraovarian autologous platelet rich plasma in women with poor ovarian reserve or ovarian insufficiency: a systematic review and meta-analysis

OBJECTIVES

To assess the value of intraovarian PRP in women with low ovarian reserve.

SEARCH STRATEGY

Screening of databases from inception to January 2023 using the keywords related to "Platelet-rich plasma" AND "poor ovarian reserve" OR "ovarian failure".

SELECTION CRITERIA

Fourteen studies (1632 participants) were included, 10 included women with POR, 1 included women with POI and 3 included both POR and POI women.

DATA COLLECTION AND ANALYSIS

Extracted data included study settings, design, sample size, population characteristics, volume, timing and preparation of PRP administration, and outcome parameters.

MAIN RESULTS

AMH level was evaluated in 11 studies (2099 women). The mean difference (MD) was 0.09 with 95% CI of - 0.06, 0.24 (P = 0.25). Antral follicular count level was assessed in 6 studies (1399 women). The MD was 1.73 with 95% CI of 0.81, 2.66 (P < 0.001). The number of oocytes retrieved was evaluated in 7 studies (1413 women). The MD was 1.21 with 95% CI of 0.48, 1.94 (P = 0.001).

CONCLUSION

This systematic review found a significant improvement of AFC, the number of retrieved oocytes, the number of cleavage embryos and the cancellation rate in women with POR.

TRIAL REGISTRATION

Registration number CRD42022365682.

The number of previous implantation failures is a critical determinant of intrauterine autologous platelet-rich plasma infusion success in women with recurrent implantation failure

Purpose

We aimed to identify factors influencing the reproductive outcomes of frozen-thawed embryo transfer (FET) with intrauterine autologous platelet-rich plasma (PRP) infusion in patients with either a thin endometrium or recurrent implantation failure (RIF) despite a normal endometrial appearance.

Methods

In this retrospective study of women who underwent PRP-FET, factors influencing PRP-FET outcomes were identified using multivariate logistic regression analysis.

Results

We enrolled 111 patients (70 with refractory thin endometrium and 41 with RIF but no thin endometrium). For 99 completed FET cycles, the β-hCG positivity rate was 46.7%, clinical pregnancy rate (CPR) was 41.0%, and live birth rate (LBR) was 36.2%. PRP treatment was associated with significant improvements over previous cycles, and participants with thin endometria demonstrated thickening. Multivariate logistic regression analysis showed that the number of previous implantation failures in women with RIF was a significant factor affecting the PRP-FET outcomes. The CPR and LBR of women with RIF were lower when there had been ≥3 previous implantation failures occurred.

Conclusions

Intrauterine PRP infusion improves the pregnancy outcomes of patients with RIF or a thin endometrium. The number of previous implantation failures is a critical determinant of successful intrauterine PRP infusions in women with RIF.

The efficacy of intrauterine infusion of platelet rich plasma in women undergoing assisted reproduction: a systematic review and meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) is an autologous platelet concentration recently used in the reproductive field. Studies had conflicting results regarding its effect on pregnancy outcomes. We aimed to solve the debate on the safety and efficacy of PRP in women undergoing assisted reproduction and assess the influence of covariates on the outcomes of PRP infusion.

METHODS

We searched PubMed, Scopus, Cochrane, and Web of Science in May 2023. We included randomized and non-randomized clinical trials as well as cohort studies assessing intrauterine PRP in sub fertile women undergoing assisted reproduction (IVF/ICSI). For the quality assessment, We used the Cochrane Risk of Bias Tool 1, the ROBINS-I tool, and the Newcastle-Ottawa Scale. We pooled the data using RevMan version 5.4.

RESULTS

The data from 23 studies were pooled. PRP had favorable outcomes compared with the control group on clinical pregnancy rate (RR: 1.84, 95% CI 1.62 to 2.09; P < 0.00001), live birth rate (RR: 1.75, 95% CI: 1.24 to 2.47; P = 0.001), and miscarriages (RR: 0.51, 95% CI: 0.36 to 0.72; P = 0.0002). Women with repeated implantation failure had a significantly improved clinical pregnancy rate (RR: 1.83, 95% CI: 1.49 to 2.24; P < 0.00001), live birth rate (RR:1.83, 95% CI: 1.33 to 2.51; P = 0.002), and miscarriage rate (RR: 0.46, 95% CI: 0.31 to 068; P = 0.0001).

CONCLUSION

PRP showed promising results in assisted reproductive techniques. Further large and multicenter RCTs are required to compare the doses of PRP while identifying the specific population with the most benefits from PRP.

Autologous Platelet-Rich Plasma (PRP) in Infertility-Infusion versus Injectable PRP

(1) Background: During IVF (in vitro fertilization) procedures, endometrial thickness has a significant role in the success of pregnancy outcomes for embryo transfers. Endometrial thickness, a crucial component of endometrial receptivity, is a contentious issue. The regenerative properties of PRP have been shown in recent research to have positive effects on the endometrium. PRP increases the pregnancy rate in IVF patients with thin endometrium and recurrent implantation failure. In order to demonstrate the efficacy of PRP therapies, this work compares the administration of injectable and infusible PRP during endometrial preparation. (2) Methods: This prospective single-arm control study was conducted at an IVF center in Oradea, Romania. This study included 50 patients; 27 were included in the group with Injectable PRP and 23 in the group with Infusible PRP. The outcome was compared between the two groups, with the primary outcome being the endometrial thickness after the PRP infusion or injection and the secondary outcome being the pregnancy rate in both groups. (3) Results: Patients who were treated with Injectable PRP had a higher pregnancy rate. An improvement in the quality of the endometrium, in terms of thickness, was also observed in the patients who were injected with PRP. (4) Conclusions: Compared to PRP infusions inside the uterus, sub-endometrial PRP injections in frozen embryo transfer methods have a greater pregnancy rate.

Factors Affecting the Potential Efficacy of Intrauterine Platelet-Rich Plasma Infusion on Thin Endometrium in Women with Recurrent Implantation Failure

Optimizing endometrial thickness (EMT) is crucial for successful embryo implantation, but enhancing thin endometrium remains a significant challenge. Platelet-rich plasma (PRP)-derived therapies have emerged as a promising approach in reproductive medicine due to their capacity to facilitate tissue repair and regeneration. This study aims to identify the risk factors associated with the failure of intrauterine PRP infusion for thin endometrium in women with recurrent implantation failure (RIF). We retrospectively reviewed data from 77 women with RIF, all exhibiting an EMT of <7 mm. These women underwent programmed hormone therapy for frozen embryo transfer (FET) and received two autologous intrauterine PRP infusions. Following intrauterine PRP-lysate (PL) infusions, the mean increase in EMT was 1.9 ± 1.2 mm, with EMT reaching 7 mm in 86% of the cases (66/77; average EMT, 8.3 mm). We identified an exceedingly thin EMT as a risk factor impacting the therapeutic efficacy in increasing EMT (p = 0.04, OR: 3.16; 95% CI: 1.03-9.67). Additionally, the number of previous uterine surgeries emerged as a prognostic factor for pregnancy failure following PL infusion (p = 0.02, OR: 2.02; 95% CI: 1.12-3.64). Our findings suggest that an extremely thin EMT and a history of numerous uterine surgeries can impede successful pregnancy, even when an optimal EMT is achieved following PRP infusion.

Autologous Platelet-Rich Plasma (PRP) Efficacy on Endometrial Thickness and Infertility: A Single-Centre Experience from Romania

(1) Background: During IVF (in vitro fertilization), a proper endometrium thickness is one of the most difficult parameters to achieve and one of the most important prognostic factors of the success rate. One major problem is the high cancelation percentage in frozen embryo transfer cycles. The focus on the adjuvant methods for improving endometrium thickness is an on-going subject of interest. (2) Methods: This prospective single-arm self-control study was conducted in an IVF centre in Oradea, Romania. The patients were divided into two groups. The control group included 51 patients with at least one attempt to transfer a good-quality blastocyst, but the endometrial thickness did not surpass 7 mm under standard endometrial preparation protocol with oestradiol and with adjuvant therapy (other than PRP, such as aspirin, vitamin C, and vitamin E), and the study group included the same 51 patients that had the embryo transfer performed under the same standard endometrial preparation protocol with oestradiol preparation protocol and intrauterine PRP infusion. (3) Results: In our study, the PRP treatment had a positive impact on the parameters that were followed for the evaluation of the success rate of the embryo transfer procedure. The endometrial thickness (an increase in endometrial thickness by 0.6 mm after PRP treatment with p = 0.0001) and the clinical pregnancy rate (having a MD ± SD of 0 ± 0.38 before PRP treatment and with an increase to 0.5 ± 0.1 after the PRP treatment, p = 0.0004) were statistically significant (4) Conclusions: PRP has a positive effect in promoting endometrial proliferation, improving embryo implantation rate and clinical pregnancy rate for women with thin endometrium.

Immune Cell Functionality during Decidualization and Potential Clinical Application

Due to a vast influx in the secretory phase of the menstrual cycle, leukocytes represent 40-50% of the decidua at the time of implantation. Their importance for the implantation, maintenance of pregnancy, and parturition are known yet not fully understood. Thus, in idiopathic infertility, decidual immune-related factors are speculated to be the cause. In this review, the immune cell functions in the decidua were summarized, and clinical diagnostics, as well as interventions, were discussed. There is a rising number of commercially available diagnostic tools. However, the intervention options are still limited and/or poorly studied. In order for us to make big steps towards the proper use of reproductive immunology findings, we need to understand the mechanisms and especially support translational research.