1
|
Cantero MM. Not all platelet-rich plasma are created equal. Curr Opin Obstet Gynecol 2024; 36:118-123. [PMID: 38324593 DOI: 10.1097/gco.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
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.
Collapse
Affiliation(s)
- Manuel Muñoz Cantero
- IVI Alicante, Centro de Excelencia en Rejuvenecimiento Ovárico, Avenida de Denia, Alicante, Spain
| |
Collapse
|
2
|
Éliás M, Kónya M, Kekk Z, Turan C, das Virgens IPA, Tóth R, Keszthelyi M, Hegyi P, Várbíró S, Sipos M. Platelet-rich plasma (PRP) treatment of the ovaries significantly improves fertility parameters and reproductive outcomes in diminished ovarian reserve patients: a systematic review and meta-analysis. J Ovarian Res 2024; 17:104. [PMID: 38760869 PMCID: PMC11100055 DOI: 10.1186/s13048-024-01423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/21/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION The incidence of infertility caused by diminished ovarian reserve has become a significant problem worldwide. The beneficial effect of PRP treatment of the ovaries has already been described, but the high-level evidence of its effectiveness has not yet been proven. MATERIALS AND METHODS A systematic search was performed in five databases, until March 12th, 2024. Both randomized and non-randomized studies that compared PRP treatment of the ovaries to self-control among women with diminished ovarian reserve were eligible for inclusion. Hormonal levels (Anti-Müllerian hormone (AMH), Follicle stimulating hormone (FSH), Luteinizing hormone (LH), Estradiol (E2), In-vitro fertilization parameters (Antral follicle count, oocyte, and embryo count), biochemical and spontaneous pregnancy and livebirth were measured. RESULTS 38 eligible studies were identified reporting on 2256 women. The level of AMH rised, the level of FSH decreased significantly after the PRP treatment. AMH 1 month MD 0.20 (n = 856, p > 0.001, 95% CI: [0.12;0.28]), 2 months MD 0.26 (n = 910, p = 0.013, 95% CI: [0.07;0.44]), 3 months MD 0.36 (n = 881, p = 0.002,95% CI: [0.20;0.52]). FSH 1 month MD -10.20 (n = 796, p > 0.039, 95% CI: [-19.80;-0.61]), 2 months MD -7.02 (n = 910, p = 0.017, 95% CI: [-12.48; -1.57]), 3 months MD -8.87 (n = 809, p = 0.010, 95% CI: [-14.19; -3.55]). The antral follicle count elevated significantly MD 1.60 (n = 1418, p = < 0.001, 95% CI: [0.92; 2.27]). Significant improvement was observed in the number of retrieved oocytes MD 0.81 (n = 802, p = 0.002, 95% CI: [0.36; 1.26]), and embryos created MD 0.91 (n = 616, p = 0.001, 95% CI: [0.45;1.36]). The incidence of spontaneous pregnancy following PRP treatment showed a rate with a proportion of 0.07 (n = 1370, 95% CI: 0.04-0.12), the rate of biochemical pregnancy was 0.18 (n = 1800, 95% CI: 0.15-0.22), livebirth was 0.11 (n = 1482, 95% CI: 0.07-0.15). CONCLUSIONS Our meta-analysis showed that based on protocolized analysis of the widest scientific literature search to date, containing predominantly observational studies, PRP treatment resulted in a statistically significant improvement in the main fertility parameters of diminished ovarian reserve women. Further multicenter, randomized trials, with large patient numbers and a longer follow-up period are needed to certify our results and develop the most effective treatment protocol.
Collapse
Affiliation(s)
- Máté Éliás
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Márton Kónya
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Zsófia Kekk
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Caner Turan
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | | | - Réka Tóth
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Márton Keszthelyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Szabolcs Várbíró
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Miklós Sipos
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
- Center of Assisted Reproduction, Semmelweis University, Budapest, Hungary.
| |
Collapse
|
3
|
Shrivastava J, More A, Shrivastava V, Choudhary N, Shrivastava D. Enhancement of Ovarian Reserve and Oocyte Quality After Platelet-Rich Plasma Instillation in a Woman With Diminished Anti-Müllerian Hormone. Cureus 2024; 16:e53474. [PMID: 38440028 PMCID: PMC10910621 DOI: 10.7759/cureus.53474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
Platelet-rich plasma (PRP) is a concentrated platelet preparation known for its regenerative properties due to the various growth factors it contains. Its application in the medical field, including dentistry, gynecology, and plastic surgery, has surged. In obstetrics and gynecology, PRP has shown promise in improving low libido, vaginal rejuvenation, ovarian reserve, and endometrial receptivity. This study presents a 29-year-old woman experiencing primary infertility attributed to low levels of anti-Müllerian hormone alongside the presence of asthenozoospermia in her husband's semen. After failed intrauterine insemination as well as in vitro fertilization (IVF), attempts at laparoscopic PRP treatment were administered before the second IVF cycle to enhance ovarian reserve and quality. The PRP treatment led to an increased follicle count, improved oocyte quality, and a successful pregnancy outcome in the second IVF cycle. PRP treatment promises to be effective in fertility treatments, potentially increasing ovarian reserve, improving oocyte quality, and enhancing successful pregnancy outcomes. This case report highlights its beneficial impact on a couple facing primary infertility, providing hope for patients with similar reproductive challenges.
Collapse
Affiliation(s)
- Jarul Shrivastava
- Clinical Embryology, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Akash More
- Clinical Embryology, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Virul Shrivastava
- Obstetrics and Gynecology, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Namrata Choudhary
- Clinical Embryology, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Deepti Shrivastava
- Obstetrics and Gynecology, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| |
Collapse
|
4
|
Serdarogullari M, Raad G, Makieva S, Liperis G, Fraire-Zamora JJ, Celik-Ozenci C. Revitalizing female fertility: platelet-rich plasma - hype or hope? Reprod Biomed Online 2024; 49:103813. [PMID: 38852205 DOI: 10.1016/j.rbmo.2024.103813] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 06/11/2024]
Abstract
Platelet-rich plasma (PRP) has gained popularity as an experimental tool in regenerative medicine, with potential applications in reproductive medicine. This review will assess the existing literature on the role of PRP in female fertility enhancement, focusing on ovarian rejuvenation and increased endometrial thickness. PRP is being explored as a treatment for recurrent implantation failure, primary ovarian insufficiency and poor ovarian response. While the influence of PRP on endometrial thickness and implantation success is postulated, its effectiveness remains the subject of debate due to protocol variability and unclear patient selection criteria. This narrative review includes 36 articles published before December 2022, and highlights the lack of comprehensive molecular studies examining the impact of PRP on reproductive capacity. This review underscores the importance of standardizing PRP preparation protocols in reproductive medicine. However, challenges persist, and there is a need for well-planned randomized controlled trials and a deeper understanding of the patient population that would gain the greatest benefit from PRP treatment. Clarifying these aspects is crucial to improve outcomes for low-prognosis patients undergoing assisted reproductive technology.
Collapse
Affiliation(s)
- Munevver Serdarogullari
- Department of Histology and Embryology, Faculty of Medicine, Cyprus International University, Northern Cyprus via Mersin 10, Turkey
| | - Georges Raad
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Jounieh, Lebanon; Al Hadi Laboratory and Medical Centre, Beirut, Lebanon
| | - Sofia Makieva
- Kinderwunschzentrum, Klinik für Reproduktions-Endokrinologie, Universitätsspital Zürich, Zurich, Switzerland
| | - Georgios Liperis
- Westmead Fertility Centre, Institute of Reproductive Medicine, University of Sydney, Westmead, NSW, Australia
| | | | - Ciler Celik-Ozenci
- Department of Histology and Embryology, School of Medicine, Koc University, Istanbul, Turkey; Koç University Research Centre for Translational Medicine, Istanbul, Turkey.
| |
Collapse
|
5
|
Boychuk AV, Kotsabyn NV, Yakymchuk JB, Nikitina IM. Pregravid preparation of women with chronic endometritis in IVF cycles. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2024; 77:25-28. [PMID: 38431803 DOI: 10.36740/wlek202401103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Aim: of our study was to improve the pregravid preparation of women with chronic endometritis to develop individual approaches to overcoming infertility, taking into account the state of endometrium. PATIENTS AND METHODS Materials and Methods: The study included 90 women (main group, n=90), 28 to 38 years with an anatomically normal uterus and chronic endometritis (CE). Patients were divided into 2 groups: group I - 45 women with CE who received conventional treatment; group II - 45 women with CE who received pregravid preparation by subendometrial injections of Platelet-Rich Plasma (PRP). RESULTS Results: At the first stage of study, the ART statistical reports from 2015 to 2022 were analyzed at the Medical Center of Reproductive Health ≪Damia≫, (Ivano-Frankivsk). Analysis of the vaginal flora parameters before treatment at the first stage revealed the presence of conditionally pathogenic flora in culture from the cervical canal (Candida albicans - 2.4%, Escherihia coli - 4.8%, Staphylococcus epidermidis - 6.2% Enterococcus faecalis - 6.9%), and was evidence of a possible recurrence of inflammation during gestation. In the age category, the groups of patients were homogeneous, with no significant differences by the level of AMH and the level of CD 138. Biochemical pregnancy be present in 20 patients (44.4%) of group I and 28 (62.2%) of group II. Fertility within a year after the end of therapy was restored with the proposed method of therapy in most women (51.1%), in the comparison group this number was 11.1% lower. Pregnancy rate between the groups (I and II) did not differ significantly. The number of live births in group II - 19 births (42.2%) - was 2 times higher than I group (9 (20.0%), P<0.05). The most common complication for women in the comparison groups was early pregnancy loss. Among 18 (40.0%) clinical pregnancies of group I, 8 women (17.8%) had early miscarriage, 1 ectopic pregnancy (2.2%), while in group II clinical pregnancy be present in 23 women (51.1%). The number of terminated pregnancies was two times lower than in the first group (8.9% vs. 17.8%, P<0.05). CONCLUSION Conclusions: Chronic endometritis is one of the main causes of pregnancy loss after in vitro fertilization. Patients of the second group were treated with the proposed method of subendometrial injections with Platelet-Rich Plasma (PRP), prepared from autologous blood, is an effective method of preparing the endometrium for embryo transfer and can increase the number of live births in patients with chronic endometritis.
Collapse
Affiliation(s)
- Alla V Boychuk
- TERNOPIL NATIONAL MEDICAL UNIVERSITY NAMED AFTER I. YA. GORBACHEVSKY, TERNOPIL, UKRAINE
| | | | - Julia B Yakymchuk
- TERNOPIL NATIONAL MEDICAL UNIVERSITY NAMED AFTER I. YA. GORBACHEVSKY, TERNOPIL, UKRAINE
| | | |
Collapse
|
6
|
Vali S, Saso S, Bracewell Milnes T, Nicopoullos J, Thum MY, Smith JR, Jones BP. The Clinical Application of Platelet-Rich Plasma in the Female Reproductive System: A Narrative Review. Life (Basel) 2023; 13:2348. [PMID: 38137949 PMCID: PMC10744710 DOI: 10.3390/life13122348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Platelet-rich plasma is an autologous plasma containing platelets prepared from fresh whole blood drawn from a peripheral vein. Through processing, it can be prepared to contain supraphysiologic levels of platelets at three to five times greater than the level of normal plasma. PRP has been explored both in vivo and ex vivo in the human endometrium model in its ability to harness the intrinsic regenerative capacity of the endometrium. Intrauterine autologous PRP infusions have been shown to increase endometrial thickness and reduce the rate of intrauterine adhesions. In the setting of recurrent implantation failure, intrauterine infusion of PRP has been shown to increase clinical pregnancy rate. PRP also appears to hold a potential role in select patients with premature ovarian insufficiency, poor ovarian responders and in improving outcomes following frozen-thawed transplantation of autologous ovarian tissue. Further studies are required to explore the potential role of PRP in reproductive medicine further, to help standardise PRP protocols and evaluate which routes of administration are most effective.
Collapse
Affiliation(s)
- Saaliha Vali
- Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK; (S.S.); (J.R.S.); (B.P.J.)
- Department of Surgery and Cancer, Imperial College London, London W12 0NN, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
| | - Srdjan Saso
- Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK; (S.S.); (J.R.S.); (B.P.J.)
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
| | - Timothy Bracewell Milnes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
- Lister Fertility Clinic, The Lister Hospital, London SW1W 8RH, UK
| | - James Nicopoullos
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
- Lister Fertility Clinic, The Lister Hospital, London SW1W 8RH, UK
| | - Meen-Yau Thum
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
- Lister Fertility Clinic, The Lister Hospital, London SW1W 8RH, UK
| | - James Richard Smith
- Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK; (S.S.); (J.R.S.); (B.P.J.)
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
| | - Benjamin P. Jones
- Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK; (S.S.); (J.R.S.); (B.P.J.)
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0NN, UK; (T.B.M.); (J.N.); (M.-Y.T.)
- Lister Fertility Clinic, The Lister Hospital, London SW1W 8RH, UK
| |
Collapse
|
7
|
Li X, Liu H, Lin G, Xu L. The effect of ovarian injection of autologous platelet rich plasma in patients with poor ovarian responder: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1292168. [PMID: 38155954 PMCID: PMC10754527 DOI: 10.3389/fendo.2023.1292168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Objective To evaluate the effects of ovarian injection of autologous platelet rich plasma (aPRP) on patients with poor ovarian responder (POR) based on the existing clinical evidence. Methods According to systematic review and meta-analysis, we comprehensively searched nine databases established as of September 6, 2023, and evaluated the impact of ovarian PRP infusion on poor ovarian responder. The research results include serum follicle-stimulating hormone(FSH) and anti-Mullerian hormone(AMH) levels, antral Follicle Count(AFC), oocyte number, and embryo number. The Newcastle Ottawa Scale (NOS) was used to evaluate the quality of inclusion in trials. Results Add up to 10 studies consisting of 793 participants were included in the meta-analysis. A review of existing evidence showed that intraovarian injection of PRP has significant therapeutic effects in increasing levels of anti-Müllerian hormone (AMH) (SMD=0.44,95% CI [0.07,0.81], p=0.02), antral follicle count (AFC) (MD=1.15,95% CI [0.4,1.90], p=0.003), oocyte count (MD=0.91, 95% CI [0.40, 1.41], p=0.0004), and embryo number (MD=0.78, 95% CI [0.5,1.07], p<0.0001). We compared the relevant data of patients before and after treatment after 2 months of intervention. It can be seen that ovarian injection of PRP treatment for 2 months has better effects in reducing FSH levels, increasing AMH levels, increasing antral follicle count, and increasing the number of oocytes and embryos (p<0.05). When the dose of PRP injected into each ovary was ≥ 4ml, there was also a significant correlation (p<0.05) with improving the number of AFC, oocytes and embryos. Significant heterogeneity existed among the studies. Conclusion The pooled results suggest that intra-ovarian injection of PRP can promote ovarian regeneration and improve the reproductive outcomes of patients with ovarian dysfunction. This therapy may have significant clinical potential in improving sex hormone levels, increasing AFC, oocyte count, and embryo count. However, this findings still requires more rigorous and extensive trials worldwide to determine the value of intra-ovarian injection of PRP in POR patients. Systematic review registration https://www.crd.york.ac.uk, Identifier CRD42023451232.
Collapse
Affiliation(s)
| | | | | | - Lianwei Xu
- Department of Gynecology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| |
Collapse
|
8
|
Ding X, Lv S, Guo Z, Gong X, Wang C, Zhang X, Meng K. Potential Therapeutic Options for Premature Ovarian Insufficiency: Experimental and Clinical Evidence. Reprod Sci 2023; 30:3428-3442. [PMID: 37460850 DOI: 10.1007/s43032-023-01300-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/10/2023] [Indexed: 12/03/2023]
Abstract
Premature ovarian insufficiency (POI) is a condition in which a woman experiences premature decline in ovarian function before the age of 40 years, manifested by menstrual disorders, decreased fertility, and possibly postmenopausal symptoms such as insomnia, hot flashes, and osteoporosis, and is one of the predominant clinical syndromes leading to female infertility. Genetic, immunologic, iatrogenic and other factors, alone or in combination, have been reported to trigger POI, yet the etiology remains unknown in most cases. The main methods currently used clinically to ameliorate menopausal symptoms due to hypoestrogenemia in POI patients are hormone replacement therapy, while the primary methods available to address infertility in POI patients are oocyte donation and cryopreservation techniques, both of which have limitations to some degree. In recent years, researchers have continued to explore more efficient and safe therapies, and have achieved impressive results in preclinical trials. In this article, we will mainly review the three most popular therapies and their related signaling pathways published in the past ten years, with the aim of providing ideas for clinical applications.
Collapse
Affiliation(s)
- Xuechun Ding
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
- College of Second Clinical Medical, Jining Medical University, Jining, China
| | - Shenmin Lv
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
- College of Second Clinical Medical, Jining Medical University, Jining, China
| | - Zhipeng Guo
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
- College of Second Clinical Medical, Jining Medical University, Jining, China
| | - Xiaowei Gong
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
- College of Second Clinical Medical, Jining Medical University, Jining, China
| | - Caiqin Wang
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
- College of Second Clinical Medical, Jining Medical University, Jining, China
| | - Xiaoyan Zhang
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
- College of Basic Medicine, Jining Medical University, Jining, China
| | - Kai Meng
- Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China.
- Lin He's Academician Workstation of New Medicine and Clinical Translation, Jining Medical University, Jining, China.
| |
Collapse
|
9
|
Caterino C, Della Valle G, Aragosa F, Cavalli S, Guccione J, Lamagna F, Fatone G. Clinical Application of Platelet Concentrates in Bovine Practice: A Systematic Review. Vet Sci 2023; 10:686. [PMID: 38133237 PMCID: PMC10747389 DOI: 10.3390/vetsci10120686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
Platelet concentrates (PCs) have become widely used in veterinary and human medicine. The PCs consist mainly of supraphysiological concentrations of platelets and, therefore, growth factors (GFs) which are stored within platelet α-granules. Among PCs, Platelet-Rich Plasma (PRP) is characterised by low-density fibrin. Research on the effect of PCs in cattle has surged in recent years; in particular, evidence has shown the positive use of PRP for treating reproductive problems, in vitro production of bovine embryos, sole ulcers and udder diseases. The aim of this report is to critically review, in accordance with the PRISMA guidelines, the available literature reporting clinical application in the bovine practice of PRP. Three bibliographic databases PubMed, Web of Science and Scopus were used for a broad search of "platelet concentrates" OR "PRP" OR "platelet-rich plasma" OR "PRF" OR "platelet-rich fibrin" AND "cows" OR "cattle". From 1196 papers, only six met the inclusion criteria. Two papers described the use of PRP in mastitis, two papers in uterine dysfunction and two papers in ovarian dysfunction. PRP offered a low-cost, easily obtained therapeutic option and showed positive results for these patients. However, given the different pathologies and definitions involved, further studies are necessary to assess its full clinical potential.
Collapse
Affiliation(s)
| | | | - Federica Aragosa
- Department of Veterinary Medicine and Animal Production, University of Naples “Federico II”, 80137 Naples, Italy; (C.C.); (G.D.V.); (S.C.); (J.G.); (F.L.); (G.F.)
| | | | | | | | | |
Collapse
|
10
|
Hassaneen ASA, Rawy MS, Yamanokuchi E, Elgendy O, Kawano T, Wakitani S, Kitahara G, Osawa T. Use of platelet lysate for in-vitro embryo production and treatment of repeat breeding in cows. Theriogenology 2023; 210:199-206. [PMID: 37523941 DOI: 10.1016/j.theriogenology.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Abstract
Platelet-rich plasma (PRP) is a biological hemocomponent derived from blood after the complete removal of red blood cells and the partial or complete removal of white blood cells to concentrate platelets in an appropriate volume of plasma. Platelets have important growth factors, cytokines, and active metabolites that improve the endometrial environment and positively affect implantation. This study evaluated the effect of the addition of activated PRP (platelets lysate; PL) on in vitro bovine oocyte maturation and embryonic development and the effect of intrauterine (IU) infusion of autologous PL in repeat breeder (RB) cows. Experiment 1 examined the effects of allogeneic PL, fetal calf serum (FCS), mixed PL + FCS, or platelet-poor plasma (PPP) supplementations to in vitro maturation and development media on in vitro oocyte maturation and embryo development in good- and poor-quality oocytes of Japanese Black cows. Experiment 2 examined the IU infusion of autologous PL, 24 h post-insemination, in 21 RB Holstein-Friesian dairy cows. The cleavage rate of good-quality oocytes was higher in the PL group (85.93 ± 2.50%) than in the PPP group (67.16 ± 3.41%) (P < 0.05), while the cleavage rate of the poor-quality oocytes was higher in the PL alone (76.13 ± 4.04%) and mixed PL + FCS treated (73.59 ± 4.22%) groups than in the PPP group (54.64 ± 2.93%) (P < 0.05). The blastocyst rate of the good-quality oocytes was higher in the PL group (40.97 ± 3.03%) than in the FCS (27.97 ± 3.31%) and PPP (25.33 ± 2.15%) groups (P < 0.05). The blastocyst rate of poor-quality oocytes and the hatching rates of both good and poor-quality oocytes showed no significant differences among all groups. The conception rate in the autologous PL-treated group was 41.67% (5/12), while it was 11.11% (1/9) in the control group. The platelets' count in the pregnant PL-treated cows (n = 5; mean ± SEM, 1.07 ± 0.10 × 109/mL) was higher than in the non-pregnant ones (n = 7; 0.67 ± 0.10 × 109/mL) (P < 0.05). In conclusion, allogeneic PL was effective in stimulating the in vitro oocyte maturation and embryonic development in both good and poor-quality bovine oocytes, and post-insemination IU infusion of autologous PL derived from high platelets' count-PRP would be recommended for the treatment of RB cows.
Collapse
Affiliation(s)
- Ahmed Saad Ahmed Hassaneen
- Department of Theriogenology, Obstetrics, and Artificial Insemination, Faculty of Veterinary Medicine, South Valley University, 83523, Qena, Egypt; Laboratory of Theriogenology, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan.
| | - Mohamed Sadawy Rawy
- Laboratory of Theriogenology, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan; Department of Theriogenology, Faculty of Veterinary Medicine, Minia University, Minia, Egypt.
| | - Eigo Yamanokuchi
- Laboratory of Theriogenology, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan.
| | - Omnia Elgendy
- Laboratory of Theriogenology, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan; Department of Theriogenology, Faculty of Veterinary Medicine, Benha University, Qalyobia, 13736, Egypt.
| | - Takanori Kawano
- Miyazaki Agricultural Mutual Aid Association, Shintomi, Miyazaki, 889-1406, Japan.
| | - Shoichi Wakitani
- Laboratory of Veterinary Anatomy, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan.
| | - Go Kitahara
- Laboratory of Theriogenology, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan.
| | - Takeshi Osawa
- Laboratory of Theriogenology, Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Miyazaki, 889-2192, Japan.
| |
Collapse
|
11
|
Moustaki M, Kontogeorgi A, Tsangkalova G, Tzoupis H, Makrigiannakis A, Vryonidou A, Kalantaridou SN. Biological therapies for premature ovarian insufficiency: what is the evidence? FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1194575. [PMID: 37744287 PMCID: PMC10512839 DOI: 10.3389/frph.2023.1194575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Premature Ovarian Insufficiency (POI) is a multi-factorial disorder that affects women of reproductive age. The condition is characterized by the loss of ovarian function before the age of 40 years and several factors have been identified to be implicated in its pathogenesis. Remarkably though, at least 50% of women have remaining follicles in their ovaries after the development of ovarian insufficiency. Population data show that approximately up to 3.7% of women worldwide suffer from POI and subsequent infertility. Currently, the treatment of POI-related infertility involves oocyte donation. However, many women with POI desire to conceive with their own ova. Therefore, experimental biological therapies, such as Platelet-Rich Plasma (PRP), Exosomes (exos) therapy, In vitro Activation (IVA), Stem Cell therapy, MicroRNAs and Mitochondrial Targeting Therapies are experimental treatment strategies that focus on activating oogenesis and folliculogenesis, by upregulating natural biochemical pathways (neo-folliculogenesis) and improving ovarian microenvironment. This mini-review aims at identifying the main advantages of these approaches and exploring whether they can underpin existing assisted reproductive technologies.
Collapse
Affiliation(s)
- Melpomeni Moustaki
- Department of Endocrinology and Diabetes Center, Hellenic Red Cross Hospital, Athens, Greece
| | | | | | | | - Antonis Makrigiannakis
- Department of Obstetrics and Gynecology, University of Crete Medical School, Heraklion, Greece
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes Center, Hellenic Red Cross Hospital, Athens, Greece
| | - Sophia N. Kalantaridou
- Serum IVF Fertility Center, Athens, Greece
- 3rd Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| |
Collapse
|
12
|
Cavalcante MB, Sampaio OGM, Câmara FEA, Schneider A, de Ávila BM, Prosczek J, Masternak MM, Campos AR. Ovarian aging in humans: potential strategies for extending reproductive lifespan. GeroScience 2023; 45:2121-2133. [PMID: 36913129 PMCID: PMC10651588 DOI: 10.1007/s11357-023-00768-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
Ovarian reserve is a term used to estimate the total number of immature follicles present in the ovaries. Between birth and menopause, there is a progressive decrease in the number of ovarian follicles. Ovarian aging is a continuous physiological phenomenon, with menopause being the clinical mark of the end of ovarian function. Genetics, measured as family history for age at the onset of menopause, is the main determinant. However, physical activity, diet, and lifestyle are important factors that can influence the age of menopause. The low estrogen levels after natural or premature menopause increased the risk for several diseases, resulting in increased mortality risk. Besides that, the decreasing ovarian reserve is associated to reduced fertility. In women with infertility undergoing in vitro fertilization, reduced markers of ovarian reserve, including antral follicular count and anti-Mullerian hormone, are the main indicators of reduced chances of becoming pregnant. Therefore, it becomes clear that the ovarian reserve has a central role in women's life, affecting fertility early in life and overall health later in life. Based on this, the ideal strategy for delaying ovarian aging should have the following characteristics: (1) be initiated in the presence of good ovarian reserve; (2) maintained for a long period; (3) have an action on the dynamics of primordial follicles, controlling the rate of activation and atresia; and (4) safe use in pre-conception, pregnancy, and lactation. In this review, we therefore discuss some of these strategies and its feasibility for preventing a decline in the ovarian reserve.
Collapse
Affiliation(s)
- Marcelo Borges Cavalcante
- Postgraduate Program in Medical Sciences, University of Fortaleza (UNIFOR), Fortaleza, CE, 60.811-905, Brazil.
| | - Olga Goiana Martins Sampaio
- Postgraduate Program in Medical Sciences, University of Fortaleza (UNIFOR), Fortaleza, CE, 60.811-905, Brazil
| | | | - Augusto Schneider
- Nutrition College, Federal University of Pelotas (UFPel), Pelotas, RS, 96010-610, Brazil
| | | | - Juliane Prosczek
- Nutrition College, Federal University of Pelotas (UFPel), Pelotas, RS, 96010-610, Brazil
| | - Michal M Masternak
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando FL, USA
- Department of Head and Neck Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Adriana Rolim Campos
- Department of Head and Neck Surgery, Poznan University of Medical Sciences, Poznan, Poland
| |
Collapse
|
13
|
Fraidakis M, Giannakakis G, Anifantaki A, Skouradaki M, Tsakoumi P, Bitzopoulou P, Kourpa S, Zervakis A, Kakouri P. Intraovarian Platelet-Rich Plasma Injections: Safety and Thoughts on Efficacy Based on a Single Centre Experience With 469 Women. Cureus 2023; 15:e38674. [PMID: 37288228 PMCID: PMC10243509 DOI: 10.7759/cureus.38674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Ovarian rejuvenation is an innovative procedure intended to restore ovarian fertility and development during the climacteric and has been used to enhance fertility in women with premature ovarian insufficiency (POI). This retrospective study was conducted to determine the effects of an intraovarian platelet-rich plasma (PRP) injection on ovarian stimulation outcomes in women referred to an in vitro fertilisation centre. Methods-Population: This was a retrospective observational study, and the inclusion criteria included women of reproductive age with at least one ovary with a history of infertility, hormonal abnormalities, an absence of a menstrual cycle, and premature ovarian failure. During the patient's first consultation, a detailed reproductive history was recorded, a pelvic scan for ovarian size was conducted, and hormonal analysis for follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), estradiol (E2), and luteinizing hormone (LH) was conducted. RESULTS In the study, 469 women with a history of infertility, hormonal abnormalities, an absence of a menstrual cycle, and premature ovarian failure had hormonal levels recorded up to four months after treatment, and these were included in the study. The volume of peripheral blood required to prepare 6-8 mL of PRP for administration was 40-60 mL. The initial concentration of platelets in the peripheral blood sample was about 25000/µL, whereas the prepared PRP had a concentration of 900.000/µL. A volume of approximately 2-4 mL per ovary, depending on the ovarian volume, was used for the intraovarian injection. PRP intervention had significant effects on FSH concentration at the α = 0.05 level. Statistically significant increases in normal values of FSH and E2were observed for months three and four after the PRP intervention for all age groups. CONCLUSIONS The results of our observational study revealed that a PRP intraovarian injection is associated with improved ovarian tissue and function. Future randomised clinical trials are needed to shed light on the use of PRP in ovarian rejuvenation before offering it routinely in clinical practice.
Collapse
Affiliation(s)
| | - Giorgios Giannakakis
- Biomedicine Laboratory, Foundation for Research and Technology-Hellas, Heraklion, GRC
| | | | | | | | | | - Sofia Kourpa
- Maternity Unit, Crete Fertility Centre, Heraklion, GRC
| | | | | |
Collapse
|
14
|
GÖKHAN A, ÇAVUŞOĞLU T, KILIÇ KD, ŞİRİN C, TOMRUK C, YİĞİTTÜRK G, ERBAŞ O, YILDIRIM SÖZMEN E, BAKA M. Effects of vitrification solution supplemented with platelet-rich plasma in rat ovarian tissue cryopreservation. Turk J Med Sci 2023; 53:1281-1292. [PMID: 38813015 PMCID: PMC10763808 DOI: 10.55730/1300-0144.5694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 10/26/2023] [Accepted: 04/04/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim The subject of this study was to investigate the utility of platelet-rich plasma (PRP) in the cryopreservation process to reduce cryodamage and increase tissue viability. Materials and methods Twenty-one female Wistar rats were randomly allocated to three groups. In Group 1 (G1), rats were not subjected to vitrification (n = 7). Group 2 (G2) was the vitrification group in which PRP was added to the basic vitrification solution (n = 7). Group 3 (G3) was the vitrification group in which fetal bovine serum was added to the basic vitrification solution (n = 7). Warmed tissues were evaluated with histochemical (HC) and immunohistochemical (IHC) staining, the TUNEL method, immunofluorescence (IF) staining, and biochemical analyses. Results The percentages of IHC staining, TUNEL method positivity, and IF staining were significantly higher in G2 compared to both G1 and G3 (P < 0.05). G2 ovaries exhibited a significant increase in both malondialdehyde and catalase values in comparison to G1 (P < 0.05). In HC staining, degenerations in primary and secondary follicles and in ovarian tissue were more common in the PRP-supplemented group. The calcium used in PRP activation was suspected to have increased the degeneration and prevented the possible positive effects of PRP. Conclusion To the best of our knowledge, PRP-supplemented vitrification solution was used for the first time in the literature in this study in whole rat ovarian tissue vitrification. If PRP is to be used as a component in vitrification solution for rat ovarian tissue, the use of lower amounts of calcium or different methods in PRP activation, or the use of nonactivated PRP, should be considered from the beginning.
Collapse
Affiliation(s)
- Aylin GÖKHAN
- Department of Histology and Embryology, Faculty of Medicine, Ege University, İzmir,
Turkiye
| | - Türker ÇAVUŞOĞLU
- Department of Histology and Embryology, Faculty of Medicine, İzmir Bakırçay University, İzmir,
Turkiye
| | - Kubilay Doğan KILIÇ
- Department of Histology and Embryology, Faculty of Medicine, Ege University, İzmir,
Turkiye
| | - Cansın ŞİRİN
- Department of Histology and Embryology, Faculty of Medicine, Ege University, İzmir,
Turkiye
| | - Canberk TOMRUK
- Department of Histology and Embryology, Republic of Turkiye Ministry of Health Samsun Education and Research Hospital, Samsun,
Turkiye
| | - Gürkan YİĞİTTÜRK
- Department of Histology and Embryology, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla,
Turkiye
| | - Oytun ERBAŞ
- Department of Physiology, Faculty of Medicine, Demiroğlu Bilim University, İstanbul,
Turkiye
| | - Eser YILDIRIM SÖZMEN
- Department of Medical Biochemistry, Faculty of Medicine, Ege University, İzmir,
Turkiye
| | - Meral BAKA
- Department of Histology and Embryology, Faculty of Medicine, Ege University, İzmir,
Turkiye
| |
Collapse
|
15
|
State of the art in assisted reproductive technologies for patients with advanced maternal age. ZYGOTE 2023; 31:149-156. [PMID: 36810125 DOI: 10.1017/s0967199422000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
According to the World Health Organization, the female reproductive age lasts up to 49 years, but problems with the realization of women's reproductive rights may arise much earlier. Significant numbers of factors affect the state of reproductive health: socioeconomic, ecological, lifestyle features, the level of medical literacy, and the state of the organization and medical care quality. Among the reasons for fertility decline in advanced reproductive age are the loss of cellular receptors for gonadotropins, an increase in the threshold of sensitivity of the hypothalamic-pituitary system to the action of hormones and their metabolites, and many others. Furthermore, negative changes accumulate in the oocyte genome, reducing the possibility of fertilization, normal development and implantation of the embryo and healthy offspring birth. Another theory of ageing causing changes in oocytes is the mitochondrial free radical theory of ageing. Taking into account all these age-related changes in gametogenesis, this review considers modern technologies aimed at the preservation and realization of female fertility. Among the existing approaches, two main ones can be distinguished: methods allowing the preservation of reproductive cells at a younger age using ART intervention and cryobanking, as well as methods aimed at improving the basic functional state of advanced-age women's oocytes and embryos.
Collapse
|
16
|
Pellicer N, Cozzolino M, Diaz-García C, Galliano D, Cobo A, Pellicer A, Herraiz S. Ovarian rescue in women with premature ovarian insufficiency: facts and fiction. Reprod Biomed Online 2023; 46:543-565. [PMID: 36710157 DOI: 10.1016/j.rbmo.2022.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 11/16/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
The ovary has a comparatively short functional lifespan compared with other organs, and genetic and pathological injuries can further shorten its functional life. Thus, preserving ovarian function should be considered in the context of women with threats to ovarian reserve, such as ageing, premature ovarian insufficiency (POI) and diminished ovarian reserve (DOR). Indeed, one-third of women with POI retain resting follicles that can be reactivated to produce competent oocytes, as proved by the in-vitro activation of dormant follicles. This paper discusses mechanisms and clinical data relating to new therapeutic strategies using ovarian fragmentation, stem cells or platelet-rich plasma to regain ovarian function in women of older age (>38 years) or with POI or DOR. Follicle reactivation techniques show promising experimental outcomes and have been successful in some cases, when POI is established or DOR diagnosed; however, there is scarce clinical evidence to warrant their widespread clinical use. Beyond these contexts, also discussed is how new insights into the biological mechanisms governing follicular dynamics and oocyte competence may play a role in reversing ovarian damage, as no technique modifies oocyte quality. Additional studies should focus on increasing follicle number and quality. Finally, there is a small but important subgroup of women lacking residual follicles and requiring oocyte generation from stem cells.
Collapse
Affiliation(s)
| | | | - César Diaz-García
- IVI London, EGA Institute for Women's Health, UCL, London, UK; IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | | | - Ana Cobo
- IVI RMA Valencia, Valencia, Spain
| | - Antonio Pellicer
- IVI RMA Rome, Rome, Italy; IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | - Sonia Herraiz
- IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain.
| |
Collapse
|
17
|
Fiorentino G, Cimadomo D, Innocenti F, Soscia D, Vaiarelli A, Ubaldi FM, Gennarelli G, Garagna S, Rienzi L, Zuccotti M. Biomechanical forces and signals operating in the ovary during folliculogenesis and their dysregulation: implications for fertility. Hum Reprod Update 2023; 29:1-23. [PMID: 35856663 DOI: 10.1093/humupd/dmac031] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Folliculogenesis occurs in the highly dynamic environment of the ovary. Follicle cyclic recruitment, neo-angiogenesis, spatial displacement, follicle atresia and ovulation stand out as major events resulting from the interplay between mechanical forces and molecular signals. Morphological and functional changes to the growing follicle and to the surrounding tissue are required to produce oocytes capable of supporting preimplantation development to the blastocyst stage. OBJECTIVE AND RATIONALE This review will summarize the ovarian morphological and functional context that contributes to follicle recruitment, growth and ovulation, as well as to the acquisition of oocyte developmental competence. We will describe the changes occurring during folliculogenesis to the ovarian extracellular matrix (ECM) and to the vasculature, their influence on the mechanical properties of the ovarian tissue, and, in turn, their influence on the regulation of signal transduction. Also, we will outline how their dysregulation might be associated with pathologies such as polycystic ovary syndrome (PCOS), endometriosis or premature ovarian insufficiency (POI). Finally, for each of these three pathologies, we will highlight therapeutic strategies attempting to correct the altered biomechanical context in order to restore fertility. SEARCH METHODS For each area discussed, a systematic bibliographical search was performed, without temporal limits, using PubMed Central, Web of Science and Scopus search engines employing the keywords extracellular matrix, mechanobiology, biomechanics, vasculature, angiogenesis or signalling pathway in combination with: ovary, oogenesis, oocyte, folliculogenesis, ovarian follicle, theca, granulosa, cumulus, follicular fluid, corpus luteum, meiosis, oocyte developmental competence, preimplantation, polycystic ovary syndrome, premature ovarian insufficiency or endometriosis. OUTCOMES Through search engines queries, we yielded a total of 37 368 papers that were further selected based on our focus on mammals and, specifically, on rodents, bovine, equine, ovine, primates and human, and also were trimmed around each specific topic of the review. After the elimination of duplicates, this selection process resulted in 628 papers, of which 287 were cited in the manuscript. Among these, 89.2% were published in the past 22 years, while the remaining 8.0%, 2.4% or 0.3% were published during the 1990s, 1980s or before, respectively. During folliculogenesis, changes occur to the ovarian ECM composition and organization that, together with vasculature modelling around the growing follicle, are aimed to sustain its recruitment and growth, and the maturation of the enclosed oocyte. These events define the scenario in which mechanical forces are key to the regulation of cascades of molecular signals. Alterations to this context determine impaired folliculogenesis and decreased oocyte developmental potential, as observed in pathological conditions which are causes of infertility, such as PCOS, endometriosis or POI. WIDER IMPLICATIONS The knowledge of these mechanisms and the rules that govern them lay a sound basis to explain how follicles recruitment and growth are modulated, and stimulate insights to develop, in clinical practice, strategies to improve follicular recruitment and oocyte competence, particularly for pathologies like PCOS, endometriosis and POI.
Collapse
Affiliation(s)
- Giulia Fiorentino
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| | | | | | - Daria Soscia
- Clinica Valle Giulia, GeneraLife IVF, Rome, Italy
| | | | | | - Gianluca Gennarelli
- Obstetrics and Gynecology, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant'Anna Hospital, University of Torino, Turin, Italy.,Livet, GeneraLife IVF, Turin, Italy
| | - Silvia Garagna
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, GeneraLife IVF, Rome, Italy.,Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Urbino, Italy
| | - Maurizio Zuccotti
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| |
Collapse
|
18
|
Hosseinisadat R, Farsi Nejad A, Mohammadi F. Intra-ovarian infusion of autologous platelet-rich plasma in women with poor ovarian reserve: A before and after study. Eur J Obstet Gynecol Reprod Biol 2023; 280:60-63. [PMID: 36403398 DOI: 10.1016/j.ejogrb.2022.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Female ovarian reserve progressively declines with increasing age. Intraovarian injection of platelet-rich plasma (PRP) seems to be an alternative treatment to increase fertility in women. Therefore, this study aimed to evaluate the effect of intra-ovarian infusion of PRP in treating women with poor ovarian reserve. MATERIALS AND METHODS In this before-and-after study, 22 infertile women with a poor ovarian reserve who underwent in vitro fertilization with the GnRH antagonist protocol were enrolled. After the oocyte retrieval undergoing vaginal ultrasound guide, PRP was injected into the ovary with a puncture needle under general anesthesia. Finally, the levels of anti-Müllerian hormone (AMH) and antral follicle counts (AFCs) were compared in all participants before and three months after the PRP injection. RESULTS Our findings showed that AMH significantly increased after the intra-ovarian infusion of PRP (P < 0.001) in these women, while no significant changes were observed in AFC (P = 0.140) at the end of the study. In addition, logistic regression indicated that body mass index (BMI) and maternal age had no significant effect on ovarian response to PRP injection. However, the duration of infertility > 5 years was associated with a 20-fold increase in the probability of AFC < 7 in women with poor ovarian reserve. CONCLUSIONS PRP can increase the chance of fertility in women with poor ovarian reserve by significantly increasing AMH levels.
Collapse
Affiliation(s)
- Robabe Hosseinisadat
- Department of Obstetrics and Gynecology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Alireza Farsi Nejad
- Department of Hematology and Laboratory Sciences, School of Paramedical Sciences, Kerman University of Medical Sciences and Health Services, Kerman, Iran; Pathology and Stem Cell Research Center, Kerman University of Medical Sciences and Health Services, Kerman, Iran.
| | - Frough Mohammadi
- Department of Obstetrics and Gynecology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| |
Collapse
|
19
|
Parvanov D, Ganeva R, Vidolova N, Nikolova K, Vasileva M, Totev T, Stamenov G. Autologous ovarian platelet rich plasma treatment improves oocyte and embryo quality: a before-after prospective study. BIOTECHNOL BIOTEC EQ 2022. [DOI: 10.1080/13102818.2022.2090280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Dimitar Parvanov
- Research Department, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| | - Rumiana Ganeva
- Research Department, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| | - Nina Vidolova
- Research Department, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| | - Kristina Nikolova
- Embryology Department, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| | - Magdalena Vasileva
- Embryology Department, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| | - Tihomir Totev
- Department of Obstetrics and Gynaecology, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| | - Georgi Stamenov
- Department of Obstetrics and Gynaecology, Nadezhda Women’s Health Hospital, Sofia, Bulgaria
| |
Collapse
|
20
|
Sills ES, Wood SH. Epigenetics, ovarian cell plasticity, and platelet-rich plasma: Mechanistic theories. REPRODUCTION & FERTILITY 2022; 3:C44-C51. [PMID: 36255031 PMCID: PMC9782453 DOI: 10.1530/raf-22-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
Ovarian platelet-rich plasma (PRP) is claimed to restore the fertility potential by improving reserve, an effect perhaps mediated epigenetically by platelet-discharged regulatory elements rather than gonadotropin-activated G-protein coupled receptors, as with stimulated in vitro fertilization (IVF). The finding that fresh activated platelet releasate includes factors able to promote developmental signaling networks necessary to enable cell pluripotency tends to support this theory. The mechanistic uncertainty of intraovarian PRP notwithstanding, at least two other major challenges confront this controversial intervention. The first challenge is to clarify how perimenopausal ovarian function is reset to levels consistent with ovulation. Perhaps a less obvious secondary problem is to confine this renewal such that any induced recalibration of cellular plasticity is kept within acceptable physiologic bounds. Thus, any 'drive' to ovarian rejuvenation must incorporate both accelerator and brake. Ovarian aging may be best viewed as a safeguard against pathologic overgrowth, where senescence operates as an evolved tumor-suppression response. While most ovary cells reach the close of their metabolic life span with low risk for hypertrophy, enhanced lysosomal activity and the proinflammatory 'senescence-associated secretory phenotype' usually offsets this advantage over time. But is recovery of ovarian fitness possible, even if only briefly prior to IVF? Alterations in gap junctions, bio-conductive features, and modulation of gene regulatory networks after PRP use in other tissues are discussed here alongside early data reported from reproductive medicine.
Collapse
Affiliation(s)
- E Scott Sills
- Office for Reproductive Research, Center for Advanced Genetics/FertiGen, San Clemente, California, USA,Regenerative Biology Group, Fertility Reserve Bank San Clemente, California, USA
| | | |
Collapse
|
21
|
Intraovarian Injection of Reconstituted Lyophilized Growth-Promoting Factor Extracted from Horse Blood Platelets (L-GF equina) Increases Oocytes Recovery and In Vitro Embryo Production in Holstein Cows. Animals (Basel) 2022; 12:ani12192618. [PMID: 36230359 PMCID: PMC9559501 DOI: 10.3390/ani12192618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 12/02/2022] Open
Abstract
The purpose of this study was to determine the impact of intraovarian injections of a reconstituted lyophilized growth-promoting factor extracted from horse blood platelets (L-GFequina) on the number of ovarian follicles, the recovery of cumulus−oocyte complexes (COCs), and embryo development to the blastocyst stage in Holstein cows. Thus, 12 Holstein cows were assigned to three protocols. According to the number of punctured follicles in protocol 1, ovum pick-up (OPU) was conducted on days 6 and 14 of the cycle (day 0 = estrus). In protocol 2, every large follicle (more than 7 mm) was removed, and 1 mL of L-GFequina was intraovarian injected (day 0). Two days later, equine chorionic gonadotropin (eCG) was administered, and OPU sessions were conducted on days 6, 10, and 14. The same ovarian stimulation procedure as that in protocol 2 was performed in protocol 3, except that equine L-GFequina was not supplied. OPU was carried out on days 6 and 10 of the cycle. The results indicate that the intraovarian injection of L-GFequina significantly (p < 0.05) increased the number of OPU sessions per cycle, the recovery of cumulus−oocyte complexes (COCs), and the production of blastocysts. In conclusion, an intraovarian injection of L-GFequina can improves OPU-IVEP results in Holstein cows.
Collapse
|
22
|
GÜRKAN N, DOKUZEYLÜL GÜNGÖR N, AYAR MADENLİ A, ALANYA TOSUN Ş. Evaluation of the impact of platelet-rich plasma in women with reduced ovarian reserve. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1117530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Infertility is the most critical factor disrupting the marital relationship, which imposes high financial and psychological costs on couples. Despite vast advances, the problem of infertility has not yet been entirely resolved. The new method of injecting platelet-rich plasma (PRP) has been promising for couples. This study investigated the effect of PRP injection on the fertility of infertile women.
Material and Method: In this study, 40 women with a history of infertility with a mean age of 37.75 were included in the study. Prior to the demographic information intervention, laboratory findings, including serum anti-mullerian hormone (AMH) levels and ultrasound for the number of antral follicles count (AFC) were performed. Autologous PRP was then prepared for each patient, and an intraovarian injection was performed. Two months after injection, serum levels of AMH and AFC levels were re-evaluated.
Results: The mean AMH levels before and after the injection were 0.07±0.05 and 0.13±0.06, respectively (p
Collapse
Affiliation(s)
- Naziye GÜRKAN
- Samsun Medical Park Hospital Gyneacology and Obstetric Clinic
| | | | | | | |
Collapse
|
23
|
Varghese J, Acharya N. Platelet-Rich Plasma: A Promising Regenerative Therapy in Gynecological Disorders. Cureus 2022; 14:e28998. [PMID: 36249659 PMCID: PMC9549690 DOI: 10.7759/cureus.28998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/10/2022] [Indexed: 11/24/2022] Open
Abstract
Platelet-rich plasma (PRP) could be understood as a special preparation of plasma in which the concentration of platelet is immensely high. This rationale for plasma use has been in the medical science for many years with plenty of success in various fields where it was inculcated, bringing dramatically favorable and better outcomes in terms of disease management and prognosis. PRP has been widely used in orthopedics from the very beginning, but in the past few years its use has been extended to other fields too, such as obstetrics and gynecology. From the very onset of the introduction of platelet-rich plasma in gynecology, there had been constant research being carried out all around the globe in order to scientifically prove and confirm its exact role in the management of gynecological problems. Regenerative medicine in gynecology was among the first areas where the platelet-rich plasma was implemented and has substantially given great results, which encouraged further extensive research to be carried out in other spectrums of gynecology. The implications of such great struggles ultimately gave way to evidence suggesting the importance of platelet-rich plasma in managing gynecological disorders like Asherman’s syndrome, urinary incontinence, genital fistulas, thin endometrium, etc. This review article collectively summarizes the various use of platelet-rich plasma in gynecology.
Collapse
|
24
|
Merhi Z, Seckin S, Mouanness M. Intraovarian platelet-rich plasma administration could improve blastocyst euploidy rates in women undergoing in vitro fertilization. Clin Exp Reprod Med 2022; 49:210-214. [PMID: 36097737 PMCID: PMC9468693 DOI: 10.5653/cerm.2021.05057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 05/19/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Platelet-rich plasma (PRP) therapy has received a considerable attention as an adjunct to fertility treatments, especially in women with very low ovarian reserve and premature ovarian insufficiency. Although recent studies have demonstrated that PRP led to improvements in folliculogenesis and biomarkers of ovarian reserve, the effect of intraovarian PRP administration on embryo genetics has not been studied. Methods We report a pilot study of patients who had preimplantation genetic testing for aneuploidy (PGT-A) before and then within 3 months following PRP administration. Twelve infertile women with at least one prior failed in vitro fertilization (IVF) cycle underwent ovarian stimulation (cycle 1) with a gentle stimulation protocol and PGT-A performed at the blastocyst stage. Following cycle 1, autologous intraovarian PRP administration was performed. Within 3 months following PRP administration, the patients underwent cycle 2 and produced blastocysts for PGT-A. The percentage of euploid embryos between both cycles was compared. Results The mean age of all participants was 40.08±1.46 years, and their mean body mass index was 26.18±1.18 kg/m2. The number of good-quality embryos formed at the blastocyst stage was similar between cycle 1 and cycle 2 (3.08±0.88 vs. 2.17±0.49, respectively; p=0.11). Among all patients in cycle 1, 3 of 37 embryos were euploid (8.11%) while in cycle 2, 11 out of 28 embryos were euploid (39.28%, p=0.002). Three clinical pregnancies were noted among this patient group. Conclusion This novel study is the first to present an improvement in the embryo euploidy rate following intraovarian PRP application in infertile women with prior failed IVF cycles. The growth factors present in PRP may exhibit a local paracrine effect that could improve meiotic aberrations in human oocytes and thus improve euploidy rates. Whether PRP improves live birth rates and lowers miscarriage rates remains to be determined in large trials.
Collapse
Affiliation(s)
- Zaher Merhi
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, SUNY Downstate Health Sciences University, New York, NY, USA
- Rejuvenating Fertility Center, New York, NY, USA
- Corresponding author: Zaher Merhi Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, SUNY Downstate Health Sciences University and Rejuvenating Fertility Center, 315 West 57th st, New York, NY 10019, USA Tel: +1-203-557-8686, E-mail:
| | - Serin Seckin
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, SUNY Downstate Health Sciences University, New York, NY, USA
| | | |
Collapse
|
25
|
Silviu‐Ionuț B, Ibănescu I, Alina V, Abdoon AS. Platelet‐rich Plasma in Animal Reproductive Medicine: Prospective and Applications. Reprod Domest Anim 2022; 57:1287-1294. [DOI: 10.1111/rda.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Borş Silviu‐Ionuț
- Research and Development Station for Cattle Breeding, Romanian Academy of Science, 707252 Dancu, Iaşi Romania
| | | | - Vlad‐Sabie Alina
- Department of Public Health, Faculty of Veterinary Medicine University of Life Sciences “Ion Ionescu de la Brad” Iaşi 700490 Iasi Romania
| | - Ahmed Sabry Abdoon
- Department of Animal Reproduction and Artificial Insemination Veterinary Research Institute National Research Centre, Dokki 12622 Cairo Egypt
| |
Collapse
|
26
|
Barad DH, Albertini DF, Molinari E, Gleicher N. Preliminary report of intraovarian injections of autologous platelet-rich plasma (PRP) in extremely poor prognosis patients with only oocyte donation as alternative: a prospective cohort study. Hum Reprod Open 2022; 2022:hoac027. [PMID: 35795849 PMCID: PMC9247703 DOI: 10.1093/hropen/hoac027] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/29/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
STUDY QUESTION
Does intraovarian injection of platelet-rich plasma (PRP) change ovarian function in patients with extremely low functional ovarian reserve (LFOR) who, otherwise, would likely only have a chance of pregnancy through third-party oocyte donation?
SUMMARY ANSWER
No clinically significant effects of PRP treatment on ovarian function were observed over 1 year of follow-up.
WHAT IS KNOWN ALREADY
Several investigators have reported improved responses to ovulation induction after treatment with PRP. However, previous published reports have involved, at most, only small case series. Whether PRP actually improves ovarian performance is, therefore, still unknown. PRP is nevertheless widely offered as an ‘established’ fertility treatment, often under the term ‘ovarian rejuvenation’.
STUDY DESIGN, SIZE, DURATION
We are reporting a prospective cohort study of 80 consecutive patients at ages 28–54 with LFOR, defined by anti-Müllerian hormone <1.1 ng/ml, FSH >12 mIU/ml or at least one prior IVF cycle with ≤3 oocytes within 1 year. The women were followed for 1 year after an intraovarian PRP procedure.
PARTICIPANTS/MATERIALS, SETTING, METHODS
PRP (1.5 ml) was injected into the cortex of ovaries with an average of 12 injections per ovary. Study participants were followed every 3 days for 2 weeks after PRP treatment with estradiol and FSH measurements and vaginal ultrasound to observe follicle growth and thereafter followed weekly. Beginning 1 month after their PRP treatment, participants underwent one or more cycles of ovarian stimulation for IVF. Outcome measures were endocrine response, and numbers of oocytes and embryos produced in response to a maximal gonadotropin stimulation before and after PRP treatment.
MAIN RESULTS AND THE ROLE OF CHANCE
In this study, women failed to demonstrate statistically significant outcome benefits from intraovarian PRP. However, two 40-year-old very poor-prognosis patients, with prior failed IVF cycles that never reached embryo transfer at other centers, achieved pregnancy, resulting in an ongoing pregnancy rate of 4.7% among patients who, following PRP, produced at least one oocyte (n = 42).
LIMITATIONS, REASONS FOR CAUTION
As an observational study of patients who performed poorly in past ovarian stimulation cycles, the improvement may be accounted for by regression to the mean. Similar considerations may also explain the occurrence of the two pregnancies.
WIDER IMPLICATIONS OF THE FINDINGS
This study demonstrates that, even in extremely poor prognosis patients due to LFOR, sporadic pregnancies are possible. The study, however, does not allow for the conclusion that those pregnancies were the consequence of PRP treatments. A case series, indeed, does not allow for such conclusions, even if results are more suggestive than here. This registered study, therefore, must be viewed as a preliminary report, with further data expected from this study but also from two other prospectively randomized ongoing registered studies with more controlled patient selection.
STUDY FUNDING/COMPETING INTEREST(S)
This work was supported by intramural funds from The Center for Human Reproduction and the not-for-profit research Foundation for Reproductive Medicine, both in New York, NY, USA. N.G. and D.H.B. are listed as co-inventors on several US patents. Some of these patents relate to pre-supplementation of hypo-androgenic infertile women with androgens, such as dehydroepiandrosterone and testosterone and, therefore, at least peripherally relate to the subject of this manuscript. They, as well as D.F.A., have also received research support, travel funds and speaker honoraria from several pharmaceutical and medical device companies, though none related to the here presented subject and manuscript. N.G. is a shareholder in Fertility Nutraceuticals and he and D.H.B. receive royalty payments from Fertility Nutraceuticals LLC. E.M. has no conflicts of interest to declare.
TRIAL REGISTRATION NUMBER
NCT04275700
Collapse
Affiliation(s)
- D H Barad
- The Center for Human Reproduction , New York, NY, USA
- The Foundation for Reproductive Medicine , New York, NY, USA
| | - D F Albertini
- The Center for Human Reproduction , New York, NY, USA
- Department of Developmental Cell Biology, Bedford Research Foundation , Bedford, MA, USA
| | - E Molinari
- The Center for Human Reproduction , New York, NY, USA
| | - N Gleicher
- The Center for Human Reproduction , New York, NY, USA
- The Foundation for Reproductive Medicine , New York, NY, USA
- Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University , New York, NY, USA
- Department of Obstetrics and Gynecology, Medical University of Vienna , Vienna, Austria
| |
Collapse
|
27
|
The use of intraovarian injection of autologous platelet rich plasma (PRP) in patients with poor ovarian response and premature ovarian insufficiency. Curr Opin Obstet Gynecol 2022; 34:133-137. [PMID: 35645011 DOI: 10.1097/gco.0000000000000784] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Intraovarian injection of platelet rich plasma (PRP) is a novel treatment for patients with poor ovarian response (POR) and primary ovarian insufficiency (POI). This article reviews the latest literature on the effect of PRP on markers of ovarian reserve, oocyte and embryo yield, and live birth for these poor prognosis patients. RECENT FINDINGS Several case series and one prospective trial have demonstrated improvements in markers of ovarian reserve in patients with POI and POR and improved oocyte and embryo yields in patients with POR. These studies report multiple live births in patients who had previously failed treatment. The positive effects of PRP persist throughout the literature despite the fact that multiple protocols for preparing and injecting PRP exist, with no consensus on the optimal protocol. SUMMARY Intra-ovarian injection of PRP is a promising new technology for poor prognosis patients. Rigorous and appropriately controlled clinical trials are warranted to confirm the utility of this treatment for improving patients' ability to successfully conceive.
Collapse
|
28
|
Cakiroglu Y, Yuceturk A, Karaosmanoglu O, Kopuk SY, Korun ZEU, Herlihy N, Scott RT, Tiras B, Seli E. Ovarian reserve parameters and IVF outcomes in 510 women with poor ovarian response (POR) treated with intraovarian injection of autologous platelet rich plasma (PRP). Aging (Albany NY) 2022; 14:2513-2523. [PMID: 35320118 PMCID: PMC9004561 DOI: 10.18632/aging.203972] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 05/27/2023]
Abstract
The aim of the current study was to characterize ovarian reserve parameters and IVF outcomes in women with a history of poor ovarian response (POR) treated with intraovarian injection of autologous platelet rich plasma (PRP). Reproductive age women (N=510; age range 30-45yo) diagnosed with POR based on Poseidon criteria were included in the study. PRP treatment resulted in higher AFC, higher serum AMH, lower serum FSH, and a higher number of mature oocytes and cleavage and blastocyst stage embryos. After PRP injection, 22 women (4.3%) conceived spontaneously, 14 (2.7%) were lost to follow up, and 474 (92.9%) attempted IVF. Among women who attempted IVF, 312 (65.8%) generated embryos and underwent embryo transfer, 83 (17.5%) achieved a pregnancy, and 54 (11.4%) achieved sustained implantation/live birth (SI/LB). In total, of the 510 women with POR and mean age of 40.3, PRP resulted in improvement of ovarian reserve parameters, a pregnancy rate of 20.5% and SI/LB rate of 12.9%. Our findings suggest that PRP treatment may be considered in women with POR. For wider clinical application, its clinical efficacy will need to be demonstrated in prospective randomized clinical trials.
Collapse
Affiliation(s)
- Yigit Cakiroglu
- Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, Sariyer, Istanbul, Turkey
- Acibadem Mehmet Ali Aydinlar University, Department of Obstetrics and Gynecology, Sariyer, Istanbul, Turkey
| | - Aysen Yuceturk
- Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, Sariyer, Istanbul, Turkey
| | - Ozge Karaosmanoglu
- Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, Sariyer, Istanbul, Turkey
| | - Sule Yildirim Kopuk
- Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, Sariyer, Istanbul, Turkey
| | - Zeynep Ece Utkan Korun
- Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, Sariyer, Istanbul, Turkey
| | - Nola Herlihy
- IVI RMA New Jersey, Basking Ridge, NJ 07920, USA
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Richard T. Scott
- IVI RMA New Jersey, Basking Ridge, NJ 07920, USA
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Bulent Tiras
- Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, Sariyer, Istanbul, Turkey
- Acibadem Mehmet Ali Aydinlar University, Department of Obstetrics and Gynecology, Sariyer, Istanbul, Turkey
| | - Emre Seli
- IVI RMA New Jersey, Basking Ridge, NJ 07920, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT 06510, USA
| |
Collapse
|
29
|
Sills ES. Why might ovarian rejuvenation fail? Decision analysis of variables impacting reproductive response after autologous platelet-rich plasma. Minerva Obstet Gynecol 2022; 74:377-385. [PMID: 35107239 DOI: 10.23736/s2724-606x.22.04996-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Experience with platelet-rich plasma (PRP) has accumulated from use in dental restoration, post-infarct myocardial repair, tendon surgery, pain management, and aesthetic enhancements. Reproductive medicine joined this arena in 2016, beginning with reports of menopause reversal and fertility recovery after autologous PRP for senescent ovaries. Although recent publications have highlighted benefits of 'ovarian rejuvenation', the absence of randomized placebo-controlled clinical trial data has limited its acceptance. Because selection bias tends to underreport negative outcomes, reliable estimates cannot be calculated for how often intraovarian PRP is unsuccessful. Ample information is available, however, to permit an operational root-cause analysis when failures are considered. This assessment uses a PRP treatment care path with a decision theory model to critique pre-intake screening, baseline audit, sample processing, ovarian tissue placement method, equipment selection, and follow-up monitoring. These branched choice points enable interventions likely to determine outcome. Specimen handling for intraovarian PRP merits particular scrutiny, since enormous variation in platelet protocols already exists across unrelated clinical areas. As a new addition to fertility practice, intraovarian PRP requires validation of safety and efficacy to gain wider support. Borrowing PRP knowledge from other domains can facilitate this goal, ideally with appreciation of aspects unique to intraovarian use.
Collapse
Affiliation(s)
- E Scott Sills
- Plasma Research Section, FertiGen CAG/Regenerative Biology Group, San Clemente, CA, USA - .,Department of Obstetrics & Gynecology, Palomar Medical Center, Escondido, CA, USA -
| |
Collapse
|
30
|
Sabouni R, Tarrab R, Kalaji D, Abbassi H. A new approach of using platelet-rich autologous plasma to increase the ovarian reservoir in a Syrian patient with ovarian insufficiency: A case report. Ann Med Surg (Lond) 2022; 73:103149. [PMID: 34976384 PMCID: PMC8683667 DOI: 10.1016/j.amsu.2021.103149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction The prevalence of Primary ovarian insufficiency (POI) is estimated to be 1–2%, resulting from many causes, including, iatrogenic causes which are becoming more common. There is no precise treatment to restore fertility in POI patients. However, new treatments -such as ovarian rejuvenation using platelet-rich autologous plasma (PRP)- are being tested and have shown promising results. We report using a new PRP injection protocol to manage a Syrian patient with ovarian insufficiency. Case presentation A 35-year-old woman with five years of primary infertility presented with decreased anti-mullerian hormone (AMH) after she underwent a laparoscopy one year ago. Where the AMH dropped from 1.07 to 0.39 ng/mL after it. She underwent an ovarian rejuvenation using PRP. Half mL of PRP was injected into every ovary, 2 mL were injected into the cervix, 7 mL intra-uterus, and 7 mL were injected intramuscularly to the patient's legs. Fifteen days following the operation, the patient's new AMH level was 0.94 ng/mL. The patient was placed on ovarian stimulation, and five days later the ultrasonography showed the development of six follicles in each ovary. Discussion Managing POI using ovarian rejuvenation is the best alternative treatment; When the donor eggs programs are not acceptable. The use of PRP in ovarian rejuvenation has been reported to be effective. Conclusion The use of PRP was beneficial in restoring fertility in a Syrian patient with ovarian insufficiency. Furthermore, the new PRP injection protocol was successful. However, more studies are needed to confirm this result. Primary ovarian insufficiency effect 1–2% of all women. It is a major problem in countries where donor eggs programs are not acceptable. Ovarian rejuvenation using platelet-rich plasma showed promising results. The combination of generalized and localized effects may enhance the outcomes.
Collapse
Affiliation(s)
- Rami Sabouni
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Rand Tarrab
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Dania Kalaji
- Department of Radiology, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Haitham Abbassi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Damascus University, Syria
| |
Collapse
|
31
|
Ovarian response to intraovarian platelet-rich plasma (PRP) administration: hypotheses and potential mechanisms of action. J Assist Reprod Genet 2022; 39:37-61. [PMID: 35175511 PMCID: PMC8866624 DOI: 10.1007/s10815-021-02385-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/17/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Platelet-rich plasma (PRP) therapy has been used as an adjunct to fertility treatments in women with very low ovarian reserve and premature ovarian insufficiency. Recent literature in both humans and animals suggest that intraovarian PRP administration in the setting of poor ovarian reserve may help ovarian function and increase the chances of pregnancy. METHODS A comprehensive literature search through PubMed, MEDLINE databases, and recent abstracts published at relevant society meetings was performed and resulted in 25 articles and 2 abstracts published that studied effect of PRP on the ovaries for the purpose of reproduction. RESULTS This review article presents all the data published to date pertaining to intraovarian PRP injection and pregnancy, both naturally and after in vitro fertilization. It also presents the most recent data on the use of ovarian PRP in in vitro and animal model studies highlighting the possible mechanisms by which PRP could impact ovarian function. CONCLUSIONS Even though recent commentaries questioned the use of PRP as an "add-on" therapy in fertility treatment because it has not been thoroughly studied, the recent basic science studies presented here could increase awareness for considering more serious research into the efficacy of PRP as an adjunct for women with poor ovarian reserve, premature ovarian insufficiency, and even early menopause who are trying to conceive using their own oocytes. Given its low-risk profile, the hypothetical benefit of PRP treatment needs to be studied with larger randomized controlled trials.
Collapse
|
32
|
Allam E, Abdel Moniem R, Soliman G. Functional and structural assessment of the possible protective effect of platelet-rich plasma against ischemia/reperfusion-induced ovarian injury in adult rats. CHINESE J PHYSIOL 2022; 65:64-71. [DOI: 10.4103/cjp.cjp_3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
|
33
|
Tülek F, Kahraman A. The effects of intra-ovarian autologous platelet rich plasma injection on IVF outcomes of poor responder women and women with premature ovarian insufficiency. J Turk Ger Gynecol Assoc 2021; 23:14-21. [PMID: 34866374 PMCID: PMC8907433 DOI: 10.4274/jtgga.galenos.2021.2021.0134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: There are controversial results regarding the administrations of platelet rich plasma (PRP) to increase in-vitro fertilization (IVF) success rates in the current literature. The aim of this study was to evaluate the effects of intra-ovarian PRP injections on IVF outcomes of poor responder women and women with premature ovarian insufficiency (POI). Material and Methods: The medical history and outcome of women receiving intra-ovarian PRP injections performed in a single tertiary center between 2018 and 2021 was retrospectively reviewed. Results: In total 71 women were included, of whom 21 were diagnosed with POI according to European Society of Human Reproduction and Embryology criteria and 50 were poor responders according to Bologna criteria. Number of retrieved oocytes, number of 2 pronuclear embryos and number of cleavage stage embryos were significantly higher in poor responder women after PRP injections. However clinical pregnancy rates and live birth delivery rates were similar before and after PRP injections in poor responders. In women with POI, 8 embryos were obtained in cycles commenced after PRP injections but no clinical pregnancies were achieved in this group of patients. Conclusion: Intra-ovarian PRP injections do not appear to increase live birth rates or clinical pregnancy rates in poor responder women or in those with POI, in this cohort.
Collapse
Affiliation(s)
- Fırat Tülek
- Department of Midwifery, Üskudar University Faculty of Health Sciences, İstanbul, Turkey.,Department of Obstetrics and Gynecology, Memorial Atasehir Hospital, İstanbul, Turkey
| | - Alper Kahraman
- Department of Obstetrics and Gynecology, Haseki Training and Research Hospital, İstanbul, Turkey
| |
Collapse
|
34
|
Farimani M, Nazari A, Mohammadi S, Anvari Aliabad R. Evaluation of intra-ovarian platelet-rich plasma administration on oocytes-dependent variables in patients with poor ovarian response: A retrospective study according to the POSEIDON criteria. Reprod Biol Endocrinol 2021; 19:137. [PMID: 34496887 PMCID: PMC8425058 DOI: 10.1186/s12958-021-00826-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/02/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Poor ovarian response (POR) is among the common findings in infertile women with no significant underlying condition. The aim of this study was to investigate the intra-ovarian potential of platelet-rich plasma (PRP) administration on oocytes-dependent variables in the POR women grouped according to the POSEIDON criteria. METHODS This retrospective study was performed on POR women with no underlying condition who have undergone intra-ovarian PRP injection. As well as patients' age, the number of total and MI, MII, and GV oocytes were extracted from the files. The laboratory variables including anti-mullerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol were also gathered. In order to reduce any bias due to the possible differences in kits or devices, a single laboratory with the highest number of cases was selected and others were excluded from the study. Then, the included cases were grouped into four according to the POSEIDON criteria and analyzed for the mentioned variables by SPSS, version 25. The statistical significance level was set as P-value < 0.05. RESULTS From 383 cases, a total number of 96 women were enrolled in this study. According to the POSEIDON criteria, group 4 (Age ≥ 35 years, AMH < 1.2 ng/mL) with the ratio of 56/96 (58.3%) had the highest prevalence among others. As the analyses showed, changes in the laboratory variables (LH, FSH, AMH, and estradiol) were not significant in almost all the groups following the intervention. Regarding the total oocytes number, PRP administration caused a significant increase in the total number in all the groups (all P < 0.05). Also, the number of MII oocytes was significantly increased following the treatment in all groups except for group 2 (Age ≥ 35 years, AMH ≥ 1.2 ng/mL; all P < 0.05). Of 96 cases, 14 (14.6%) got clinically pregnant following assisted reproductive techniques which this number were significantly differed among the groups (P = 0.002). CONCLUSION This study showed that PRP treatment was effective on total and MII oocyte numbers in the patients with POR, however, further studies are required.
Collapse
Affiliation(s)
- Marzieh Farimani
- Endometrium and Endometriosis Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Arash Nazari
- School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Roghayeh Anvari Aliabad
- Endometrium and Endometriosis Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
- Department of Gynecology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran.
- Endometrium and Endometriosis Research Center, Fatemieh Hospital, Pasdaran Street, P.O. Box, 89971-65177, Hamadan, Iran.
| |
Collapse
|
35
|
das Neves J, Notario-Pérez F, Sarmento B. Women-specific routes of administration for drugs: A critical overview. Adv Drug Deliv Rev 2021; 176:113865. [PMID: 34280514 DOI: 10.1016/j.addr.2021.113865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/19/2022]
Abstract
The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.
Collapse
|
36
|
Sfakianoudis K, Rapani A, Grigoriadis S, Retsina D, Maziotis E, Tsioulou P, Giannelou P, Pantos K, Koutsilieris M, Vlahos N, Mastorakos G, Simopoulou M. Novel Approaches in Addressing Ovarian Insufficiency in 2019: Are We There Yet? Cell Transplant 2021; 29:963689720926154. [PMID: 32686983 PMCID: PMC7563844 DOI: 10.1177/0963689720926154] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Ovarian insufficiency is described as a multifaceted issue typically encountered in the field of assisted reproduction. The three main identified diagnoses of ovarian insufficiency include premature ovarian failure (POF), poor ovarian response (POR), and advanced maternal age (AMA). Patient heterogeneity in the era of individualized medicine drives research forward leading to the emergence of novel approaches. This plethora of innovative treatments in the service of adequately managing ovarian insufficiency is called to undertake the challenge of addressing infertile patients exploring their reproductive options. This review provides an all-inclusive presentation and critical analysis on novel treatments that have not achieved routine clinical practice status yet, but have recently emerged as promising. In light of the lack of randomized controlled trials conveying safety and efficiency, clinicians are left puzzled in addressing the "how" and "for whom" these approaches may be beneficial. From ovarian injection employing platelet-rich plasma (PRP) or stem cells to artificial gametes and ovaries, ovarian transplantation, and mitochondrial replacement therapy, this descriptive review provides insight toward assisting the practitioner in decision making regarding these cutting-edge treatments. Biological mechanisms, invasiveness levels, efficiency, as well as possible complications, the current status along with bioethical concerns are discussed in the context of identifying future optimal treatment.
Collapse
Affiliation(s)
| | - Anna Rapani
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sokratis Grigoriadis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Retsina
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Unit of Endocrinology, Diabetes Mellitus and Metabolism, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Maziotis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Petroula Tsioulou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Polina Giannelou
- Centre for Human Reproduction, Genesis Athens Clinic, Athens, Greece.,Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Michael Koutsilieris
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Vlahos
- Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Mastorakos
- Unit of Endocrinology, Diabetes Mellitus and Metabolism, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Mara Simopoulou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
37
|
Atkinson L, Martin F, Sturmey RG. Intraovarian injection of platelet-rich plasma in assisted reproduction: too much too soon? Hum Reprod 2021; 36:1737-1750. [PMID: 33963408 PMCID: PMC8366566 DOI: 10.1093/humrep/deab106] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/09/2021] [Indexed: 12/13/2022] Open
Abstract
The prospect of ovarian rejuvenation offers the tantalising prospect of treating age-related declines in fertility or in pathological conditions such as premature ovarian failure. The concept of ovarian rejuvenation was invigorated by the indication of the existence of oogonial stem cells (OSCs), which have been shown experimentally to have the ability to differentiate into functional follicles and generate oocytes; however, their clinical potential remains unknown. Furthermore, there is now growing interest in performing ovarian rejuvenation in situ. One proposed approach involves injecting the ovary with platelet rich plasma (PRP). PRP is a component of blood that remains after the in vitro removal of red and white blood cells. It contains blood platelets, tiny anucleate cells of the blood, which are responsible for forming athrombus to prevent bleeding. In addition, PRP contains an array of cytokines and growth factors, as well as a number of small molecules.The utility ofPRP has been investigatedin a range of regenerative medicine approaches and has been shown to induce differentiation of a range of cell types, presumably through the action of cytokines. A handful ofcasereports have described the use of PRP injections into the ovaryin the human, and while these clinical data report promising results, knowledge on the mechanisms and safety of PRP injections into the ovary remain limited.In this article, we summarise some of the physiological detail of platelets and PRP, before reviewing the existing emerging literature in this area. We then propose potential mechanisms by which PRP may be eliciting any effects before reflecting on some considerations for future studies in the area. Importantly, on the basis of our existing knowledge, we suggest that immediate use of PRP in clinical applications is perhaps premature and further fundamental and clinical research on the nature of ovarian insufficiency, as well as the mechanism by which PRP may act on the ovary, is needed to fully understand this promising development.
Collapse
Affiliation(s)
- Lloyd Atkinson
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK
| | - Francesca Martin
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK
| | - Roger G Sturmey
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK.,Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, St Mary's Hospital, Manchester, UK
| |
Collapse
|
38
|
Merhi Z, Seckin S, Mouanness M. Intraovarian PRP Injection Improved Hot Flashes in a Woman With Very Low Ovarian Reserve. Reprod Sci 2021; 29:614-619. [PMID: 34231167 DOI: 10.1007/s43032-021-00655-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
PRP, rich in growth factors and cytokines, has been gaining considerable attention as an adjunct therapy to fertility treatment for women with very low ovarian reserve and premature ovarian insufficiency. To date, most prior studies have focused on the effect of PRP on ovarian response pertaining to oocyte production and pregnancy outcome following assisted reproductive technology. This report presents a patient with very low ovarian reserve, with medical problems that preclude her from taking hormone replacement therapy, who presented for fertility treatment with PRP and then accidentally reported significant improvement of menopausal symptoms including her hot flashes for 14 weeks following PRP intra-ovarian injection. The purpose of this case report is to increase awareness of clinicians about the use of PRP as a potential alternative therapy for hot flashes in women who have contraindications for hormone replacement therapy.
Collapse
Affiliation(s)
- Zaher Merhi
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, SUNY Downstate Health Sciences University, Brooklyn, NY, USA. .,Rejuvenating Fertility Center, New York City, NY, USA. .,Department of Biochemistry, Albert Einstein College of Medicine, Brooklyn, NY, USA.
| | - Serin Seckin
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | | |
Collapse
|
39
|
The Scientific and Cultural Journey to Ovarian Rejuvenation: Background, Barriers, and Beyond the Biological Clock. MEDICINES 2021; 8:medicines8060029. [PMID: 34201170 PMCID: PMC8228162 DOI: 10.3390/medicines8060029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022]
Abstract
Female age has been known to define reproductive outcome since antiquity; attempts to improve ovarian function may be considered against a sociocultural landscape that foreshadows current practice. Ancient writs heralded the unlikely event of an older woman conceiving as nothing less than miraculous. Always deeply personal and sometimes dynastically pivotal, the goal of achieving pregnancy often engaged elite healers or revered clerics for help. The sorrow of defeat became a potent motif of barrenness or miscarriage lamented in art, music, and literature. Less well known is that rejuvenation practices from the 1900s were not confined to gynecology, as older men also eagerly pursued methods to turn back their biological clock. This interest coalesced within the nascent field of endocrinology, then an emerging specialty. The modern era of molecular science is now offering proof-of-concept evidence to address the once intractable problem of low or absent ovarian reserve. Yet, ovarian rejuvenation by platelet-rich plasma (PRP) originates from a heritage shared with both hormone replacement therapy (HRT) and sex reassignment surgery. These therapeutic ancestors later developed into allied, but now distinct, clinical fields. Here, current iterations of intraovarian PRP are discussed with historical and cultural precursors centering on cell and tissue regenerative effects. Intraovarian PRP thus shows promise for women in menopause as an alternative to conventional HRT, and to those seeking pregnancy—either with advanced reproductive technologies or as unassisted conceptions.
Collapse
|
40
|
Emerging follicular activation strategies to treat women with poor ovarian response and primary ovarian insufficiency. Curr Opin Obstet Gynecol 2021; 33:241-248. [PMID: 33896920 DOI: 10.1097/gco.0000000000000703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF THE REVIEW Female reproductive aging remains one of the key unsolved challenges in the field of reproductive medicine. This article reviews three of the most recent and cutting-edge strategies that are currently being investigated to address the issues of poor ovarian response (POR) and primary ovarian insufficiency (POI). RECENT FINDINGS Publications revealing the mechanism of mechanical disruption of the Hippo signaling pathway paved the way to studies on its potential application for fertility treatments. This, in combination with Akt stimulation, resulted in live births and ongoing pregnancies in women with POI. Building on previous reports on the effects of bone marrow transplants on fertility after chemotherapy, another approach involved autologous stem cell ovarian transplantation (ASCOT). The method proved effective in achieving live births in women previously diagnosed with POR. A third approach, intraovarian injection of autologous platelet-rich plasma, resulted in live births and ongoing pregnancies both spontaneously and via in vitro fertilization (IVF) in women with POI and POR. SUMMARY New paths are being charted to address the issues of POI and POR. Although these are preliminary studies that should be interpreted with caution, they represent great promise for the women affected by these conditions and the physicians treating them.
Collapse
|
41
|
Human Mesenchymal Stem Cell Therapy and Other Novel Treatment Approaches for Premature Ovarian Insufficiency. Reprod Sci 2021; 28:1688-1696. [PMID: 33956339 PMCID: PMC8144118 DOI: 10.1007/s43032-021-00528-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/01/2021] [Indexed: 12/11/2022]
Abstract
Premature ovarian insufficiency (POI) is a condition characterized by amenorrhea, hypergonadotropic hypogonadism, estrogen deficiency, and reduced follicle counts leading to infertility under the age of 40. POI occurs in approximately 1-3% of women in the general population. Evaluation is warranted when the diagnosis of POI is made to rule out underlying etiologies, which could be multifactorial. This review serves to cover the novel treatment approaches reported in the literature.
Collapse
|
42
|
Resumed ovarian function and pregnancy in early menopausal women by whole dimension subcortical ovarian administration of platelet-rich plasma and gonadotropins. ACTA ACUST UNITED AC 2021; 28:660-666. [PMID: 33784262 DOI: 10.1097/gme.0000000000001746] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study was designed to investigate if whole dimension subcortical ovarian administration of platelet-rich plasma with gonadotropin, in proximity to most ovarian follicles, is effective in restoring ovarian functions in women during early menopause. METHODS Platelet-rich plasma, prepared from 40 mL of autologous peripheral blood using the buffy coat method, was injected into extended subcortical area of bilateral ovaries along with recombinant follicle-stimulating hormone (rFSH) (Gonal-F 300IU) under laparoscopic guidance. The posttreatment ovarian folliculogenesis and serum levels of FSH, luteinizing hormone (LH), and estradiol were followed up for 6 months at weekly to monthly intervals. IVF was carried out in women resuming ovulatory functions. RESULTS Twelve early menopausal women with mean age of 44.42 ± 2.84 were enrolled. After treatment, 11 women resumed their menstrual period in 37.1 ± 23.5 days. Their average serum FSH was 70.47 ± 20.92 and 26.22 ± 17.55 IU/L, luteinizing hormone was 34.81 ± 11.86 and 14.3 ± 12.8 IU/L, before and after treatment, respectively. The mid-cycle E2 was 251.1 ± 143.8 pg/mL. Ten oocyte retrievals were carried out among six participants, four of them received controlled ovarian stimulation and another two using natural ovulation cycles. Thirteen mature eggs were retrieved which were then ICSI fertilized to obtain 10 normally fertilized 2PN oocytes. Two participants had cleavage stage embryos transferred of which one achieved clinical pregnancy. CONCLUSIONS Whole dimension subcortical ovarian administration of platelet-rich plasma with gonadotropin was shown to restore ovarian functions, at least temporarily, and could increase the probability of pregnancy using autologous oocytes in women with early menopause.
Collapse
|
43
|
Magarmanova S, Ukbaeva T. APPLICATION OF AUTOLOGOUS PLATELET-RICH PLASMA IN REPRODUCTIVE MEDICINE. REPRODUCTIVE MEDICINE 2021. [DOI: 10.37800/rm2021-1-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
By definition, platelet-rich plasma (PRP) is a biological product, a part of the plasma fraction of blood, with a platelet concentration exceeding the normal physiological value. PRP is widely used in orthopedics and sports medicine to eliminate pain symptoms by stimulating natural healing processes. In recent years, there have been reports about using of PRP in assisted reproductive technologies. This article presents an overview of information on the mechanism of action PRP, classification of platelet concentrates and its clinical application in the field of reproductive medicine.
Collapse
|
44
|
A narrative review of platelet-rich plasma (PRP) in reproductive medicine. J Assist Reprod Genet 2021; 38:1003-1012. [PMID: 33723748 DOI: 10.1007/s10815-021-02146-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/07/2021] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research. METHODS A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure. RESULTS In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure. CONCLUSIONS Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.
Collapse
|
45
|
Effects of Intraovarian Injection of Autologous Platelet-Rich Plasma on Ovarian Rejuvenation in Poor Responders and Women with Primary Ovarian Insufficiency. Reprod Sci 2021; 28:2050-2059. [PMID: 33683669 DOI: 10.1007/s43032-021-00483-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/31/2021] [Indexed: 12/25/2022]
Abstract
Injection of intraovarian platelet-rich plasma (PRP) was recently presented in terms of improvement ovarian function in women with a poor ovarian response (POR) or primary ovarian insufficiency (POI). In a before and after study, 17 poor responder women and 9 women with the diagnosis of POI were recruited. The multifocal intramedullary infusion of 1.5 ml activated PRP was performed into each ovary. The majority of women in both groups received the second PRP injection with the twofold increase in the dosage to 3ml, 3 months after the first injection. Evaluation of serum anti-mullerian hormone ( AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) was performed. In addition, all women were followed with regard to pregnancy outcome up to delivery. In the POI group, menstrual restoration was monitored. The significant difference was not detected regarding the hormonal profile between the three time points in both groups. With regard to pregnancy outcome, 8/17 (47%) of PORs had spontaneous pregnancy in response to PRP injection. Of those, three women (37.55%) had abortions, whereas 4 pregnancies (50%) led to healthy live births, and one woman (12.5%) was in the 24th week of her pregnancy. Menstruation recovery occurred among 22.2% of women with POI after the second PRP injection, but no one became pregnant. Intraovarian injection of autologous PRP might be considered an alternative treatment in poor responders. As for women with POI, it is questionable whether PRP could induce menstrual recovery.
Collapse
|
46
|
Hajipour H, Farzadi L, Latifi Z, Keyhanvar N, Navali N, Fattahi A, Nouri M, Dittrich R. An update on platelet-rich plasma (PRP) therapy in endometrium and ovary related infertilities: clinical and molecular aspects. Syst Biol Reprod Med 2021; 67:177-188. [PMID: 33632047 DOI: 10.1080/19396368.2020.1862357] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Administration of platelet-rich plasma (PRP) is one of the well-recommended strategies for the treatment of endometrium- and ovary-associated infertility. Due to the autologous source of PRP, minimal risks for disease transmission and immunogenic and allergic responses are expected in this method. Despite the extensive use of PRP in medicine, its precise mechanism of action in endometrial and ovarian tissues is still unknown. Nevertheless, the induction of cell proliferation, chemotaxis, regeneration, extracellular matrix synthesis, remodeling, angiogenesis, and epithelialization are the main pathways for PRP to affect female reproductive organs. Given the promising results of previous studies, it is necessary to standardize PRP preparation protocols for different therapeutic purposes and also clearly determine appropriate inclusion and exclusion criteria for recruiting patients. In the current review, we presented a summary of studies on PRP therapy for endometrium- and ovary-associated infertility with a focus on the possible mechanisms by which PRP enhances endometrial receptivity and regenerates ovarian function.Abbreviations: PRP: platelet-rich plasma; ART: assisted reproductive technology; POF: premature ovarian failure; TGF: transforming growth factors; PDGF: platelet-derived growth factors; IGF-I: insulin-like growth factor-1; HGF: hepatocyte growth factor; EGF: epidermal growth factor; FGF: fibroblast growth factor; VEGF: vascular endothelial growth factor; ADP: adenosine diphosphate, ATP: adenosine triphosphate; PDGF: platelet-derived growth factor; COX2: cyclooxygenase-2; TP53: tumor protein 53; ER-α: estrogen receptors alpha; ER-β: estrogen receptors beta; PR: progesterone receptor; RIF: recurrent implantation failure; G-CSF: granulocyte colony-stimulating factor; iNOS: inducible nitric oxide synthase; NF-kβ: nuclear factor kappa beta; MMPs: matrix metalloproteinases; Col1a1: collagen type I alpha 1; IL: interleukin; FSH: follicle-stimulating hormone; AMH: anti-Mullerian hormone; GDF-9: growth differentiation factor 9.
Collapse
Affiliation(s)
- Hamed Hajipour
- Department of Reproductive Biology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Laya Farzadi
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zeinab Latifi
- Department of Biochemistry and Clinical Laboratories, Faculty of Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Keyhanvar
- Stem Cell and Regenerative Medicine Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazli Navali
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Fattahi
- Department of Reproductive Biology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran.,OB/GYN, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Mohammad Nouri
- Department of Reproductive Biology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ralf Dittrich
- OB/GYN, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| |
Collapse
|
47
|
Sills ES, Rickers NS, Wood SH. Intraovarian insertion of autologous platelet growth factors as cell-free concentrate: Fertility recovery and first unassisted conception with term delivery at age over 40. Int J Reprod Biomed 2021; 18:1081-1086. [PMID: 33426419 PMCID: PMC7778756 DOI: 10.18502/ijrm.v18i12.8030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/09/2020] [Accepted: 11/08/2020] [Indexed: 11/24/2022] Open
Abstract
Background The use of autologous platelet-rich plasma as an ovarian treatment has not been standardized and remains controversial. Case Presentation A 41½-year old woman with diminished ovarian reserve (serum anti- Müllerian hormone = 0.163 mg/mL) and a history of 10 unsuccessful in vitro fertilization cycles presented for reproductive endocrinology consult. She and her partner declined donor oocyte in vitro fertilization. They were both in good general health and laboratory tests were unremarkable, except for mild thrombocytosis (platelets = 386K; normal range 150-379K) discovered in the female. The patient underwent intraovarian injection of fresh platelet-derived growth factor concentrate administered as an enriched cell-free substrate. Serum anti- Müllerian hormone increased by 115% within 6 wks of treatment. Spontaneous ovulation occurred the month after injection and subsequently the serum human chorionic gonadotropin was noted at 804 mIU/mL. Following an uneventful obstetrical course, a male infant was delivered at term without complication. Conclusion This is the first description of intraovarian injection of enriched platelet-derived growth factors followed by unassisted pregnancy and live birth. As a refinement of conventional ovarian platelet-rich plasma therapy, this procedure may be particularly valuable for refractory cases where prognosis for pregnancy appears especially bleak. A putative role for thrombocytosis is also viewed in parallel with mechanisms of action as advanced earlier. With continued experience in ovarian application of autologous platelet growth factors, additional research will evaluate laboratory protocol/sample preparation, injection technique, and patient selection.
Collapse
Affiliation(s)
- E Scott Sills
- Reproductive Biology Group IVF, FertiGen CAG; San Clemente, California USA.,Department of Obstetrics and Gynecology, Palomar Medical Center; Escondido, California USA.,Gen 5 Fertility Center; San Diego, California USA
| | - Natalie S Rickers
- Reproductive Biology Group IVF, FertiGen CAG; San Clemente, California USA.,Gen 5 Fertility Center; San Diego, California USA
| | - Samuel H Wood
- Department of Obstetrics and Gynecology, Palomar Medical Center; Escondido, California USA.,Gen 5 Fertility Center; San Diego, California USA
| |
Collapse
|
48
|
Abstract
Advanced maternal age is associated with the natural oocyte depletion, leading to low oocyte yield, high infertility treatment cancellation rates, and eventual decreases in pregnancy rates. Various innovative interventions have been introduced to improve the outcome of infertility treatment for aging patients. Numerous published data demonstrated that early follicle development was regulated by intraovarian growth factors through autocrine or paracrine mechanisms. Platelet-rich plasma (PRP), a plasma fraction of peripheral blood with a high concentration of platelets, has been implemented in regenerative medicine in the last decade. The plasma contains a variety of growth factors that were suggested to be able to enhance angiogenesis regeneration and the cell proliferation process. The initial report showed that an intraovarian injection of PRP improved the hormonal profile and increased the number of retrieved oocytes in patients with diminished ovarian reserve. Subsequently, several studies with larger sample sizes have reported that this approach resulted in several healthy live births with no apparent complications. However, the use of ovarian PRP treatment needs to be fully investigated, because no randomized controlled trial has yet been performed to confirm its efficacy.
Collapse
|
49
|
Ishizuka B. Current Understanding of the Etiology, Symptomatology, and Treatment Options in Premature Ovarian Insufficiency (POI). Front Endocrinol (Lausanne) 2021; 12:626924. [PMID: 33716979 PMCID: PMC7949002 DOI: 10.3389/fendo.2021.626924] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/20/2021] [Indexed: 12/16/2022] Open
Abstract
Premature ovarian insufficiency (POI) occurs in at least 1% of all women and causes life-long health problems and psychological stress. Infertility caused by POI used to be considered absolute, with infertility treatment having little or no value. Generally, it has been thought that medicine can provide little service to these patients. The etiology of POI has been found to be genetic, chromosomal, and autoimmune. In addition, the increasing numbers of cancer survivors are candidates for iatrogenic POI, along with patients who have undergone ovarian surgery, especially laparoscopic surgery. Over 50 genes are known to be causally related to POI, and the disease course of some cases has been clarified, but in most cases, the genetic background remains unexplained, suggesting that more genes associated with the etiology of POI need to be discovered. Thus, in most cases, the genetic background of POI has not been clarified. Monosomy X is well known to manifest as Turner's syndrome and is associated with primary amenorrhea, but recent studies have shown that some women with numerical abnormalities of the X chromosome can have spontaneous menstruation up to their twenties and thirties, and some even conceive. Hormone replacement therapy (HRT) is recommended for women with POI from many perspectives. It alleviates vasomotor and genitourinary symptoms and prevents bone loss and cardiovascular disease. POI has been reported to reduce quality of life and life expectancy, and HRT may help improve both. Most of the problems that may occur with HRT in postmenopausal women do not apply to women with POI; thus, in POI, HRT should be considered physiological replacement of estrogen (+progesterone). This review describes some new approaches to infertility treatment in POI patients that may lead to new treatments for POI, along with the development of more sensitive markers of secondary/preantral follicles and genetic diagnosis.
Collapse
Affiliation(s)
- Bunpei Ishizuka
- Rose Ladies Clinic, Tokyo, Japan
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
- *Correspondence: Bunpei Ishizuka,
| |
Collapse
|
50
|
Girsh E, Harlev A, Grin L. IN-VITRO ACTIVATION OF OVARIAN FOLLICULAR RESIDUAL RESERVE. REPRODUCTIVE MEDICINE 2020. [DOI: 10.37800/rm2020-1-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The newly developed in-vitro activation (IVA) method provides a novel fertility treatment for patients with premature ovarian insufficiency. The IVA method pretends to promote growth of residual ovarian follicles at early stages of their development. Based on preliminary data, poor ovarian response (POR) patients with decreased ovarian reserve (DOR) who have multiple secondary follicles, IVA is a promising technique to promote growth of secondary follicle as well.
Collapse
|