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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 81-85

Intrauterine autologous platelet-rich plasma therapy to improve implantation rates in patients undergoing frozen embryo transfer: A pilot study


Department of Reproductive Medicine, Mother and Child Hospital, New Delhi, India

Date of Web Publication22-Feb-2019

Correspondence Address:
Jasneet Kaur
Department of Reproductive Medicine, Mother and Child Hospital, D-59, Defence Colony, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tofj.tofj_11_18

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  Abstract 


Background: Successful implantation is a well-orchestrated event requiring the presence of a healthy embryo, a receptive endometrium, appropriate embryo endometrial cross-talk, and adequate maternal immune protection. Despite advances in assisted reproductive technology, there are insignificant improvements in the implantation and pregnancy rates. Intrauterine infusion of platelet-rich plasma (PRP) might improve implantation rates through its paracrine effects by recruiting growth factors and cytokines that favor decidualization and implantation.
Objectives: The objective of the study is to study whether intrauterine PRP improves implantation rates in patients undergoing frozen embryo transfer (FET).
Subjects and Methods: In this retrospective study, we collected data of patients who underwent FET in Mother and Child Hospital for 11 months from January 2018 to November 2018. We screened data of 98 patients who had at least one previous failed FET and underwent subsequent FET. The patients were divided into a study and control group. The study group received Intrauterine PRP before FET, while the control group did not. All patients underwent the same hormone replacement therapy regimen for endometrial preparation.
Main Outcome Measure: The main outcomes studied were the implantation rates and clinical pregnancy rates (CPR) after embryo transfer.
Results: Patient demographics such as mean age, body mass index, and anti-mullerian hormone of both groups were comparable. Overall, the CPR was 42.8% in the control group and 47.6% in the intervention group, and the difference was not statistically significant.
Conclusion: Intrauterine PRP does not increase the implantation rates/CPR significantly in patients who have had one previous FET failure.

Keywords: Frozen embryo transfer, implantation rates, intrauterine platelet rich plasma


How to cite this article:
Madhavan A, Naidu P, Rani KK, Kaur J, Mahajan N. Intrauterine autologous platelet-rich plasma therapy to improve implantation rates in patients undergoing frozen embryo transfer: A pilot study. Onco Fertil J 2018;1:81-5

How to cite this URL:
Madhavan A, Naidu P, Rani KK, Kaur J, Mahajan N. Intrauterine autologous platelet-rich plasma therapy to improve implantation rates in patients undergoing frozen embryo transfer: A pilot study. Onco Fertil J [serial online] 2018 [cited 2019 Jul 18];1:81-5. Available from: http://www.tofjonline.org/text.asp?2018/1/2/81/252686




  Introduction Top


Human reproduction is a relatively inefficient process with cycle fecundity rates being in the range of 20%–25% and this figure does not seem to improve significantly with assisted reproductive technology (ART) with cumulative pregnancy rates of 40%–60% being reported.[1] Successful implantation is a well-orchestrated event requiring the presence of a healthy embryo, a receptive endometrium, appropriate embryo – endometrial cross-talk, and adequate maternal immune protection. The maternal immune response is intricately linked to successful implantation though the exact mechanism is unclear.[2] Advances have been made to improve ART outcomes by changes in the protocols for ovarian stimulation, frozen embryo transfers (FETs), selection of the euploid embryos by preimplantation genetic testing for aneuploidy (PGT-A), and assessing the accurate window of implantation using tools such as ER array (ERA). In addition, efforts have been made to improve endometrial receptivity by intrauterine instillation of granulocyte colony-stimulating factor, endometrial scratching, using immunomodulators such as intralipids, IVIG, low-dose aspirin, and low molecular heparins.[2] Despite these efforts, there has been no significant improvement in the pregnancy rates in in vitro fertilization (IVF) in the last decade.

Platelet-rich plasma (PRP) is defined as a plasma fraction of autologous blood with the concentration of platelets four to five times above normal.[3] Autologous PRP has been proposed as a safe, easily available, and inexpensive treatment modality for women with refractory endometrium and implantation failures.[4],[5],[6],[7],[8] Platelets contain a cocktail of chemical mediators in their alpha granules which through activating platelets in PRP, become bioactive. These factors include vascular endothelial growth factor (VEGF), transforming growth factor (TGF), platelet-derived growth factor (PDGF), and epidermal growth factor. These substances have an antiapoptotic effect on endothelial cells, are involved in the chemotaxis of endothelial cells, and cause proliferation and promotion of adhesion bonds form.[3] Few studies have suggested a role for PRP in patients with thin refractory endometrium; however, its role in patients with implantation failures is less widely studied.[4],[5],[6],[7],[8] It is used in reproductive medicine to improve implantation rates is based on the premise that PRP through a paracrine effect recruits growth factors that favor decidualization and implantation.

The aim of our study was to determine whether intrauterine infusion of autologous PRP enhances the outcomes of FET in patients who had at least one previous failed FET with a transfer of two good quality embryos.


  Subjects and Methods Top


Source of data

We did a retrospective analysis of 98 patients who had at least one failed FET and underwent subsequent FET at our center for 11 months from January 2018 to November 2018.

Patients were divided into two groups. The study group had 42 patients who received intrauterine infusion of PRP on day 8/9 of the hormone replacement therapy (HRT) cycle. Control group contained 56 patients who did not receive any PRP [Table 1].
Table 1: General characteristics and in vitro fertilisation outcome of patients of the study population

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Inclusion criteria

Patients aged 25–40 years undergoing FET who had at least one previous FET failure with two good cleavage stage embryos or blastocysts, derived from autologous oocytes in an endometrium 7 mm or more in thickness.

Exclusion criteria

Known uterine abnormalities, previous history of endometrial disease such as atypia or Asherman's disease, known genetic diseases, cancer, comorbid conditions which might affect IVF success, nonconsented patients.

Hormone replacement therapy regime

All patients underwent the same HRT regimen for endometrial preparation. Estradiol valerate (E2V) was started in a dose of 4 mg orally from the 2nd or 3rd day of the menstrual cycle and was escalated to 6 mg after 4 days. The maximal dose of E2V given was 12 mg. Transdermal E2V was used in patients who could not tolerate oral intake. Serial ultrasound examinations were performed using an 8MHz transvaginal probe. Vaginal progesterone (P) in a dose of 400 mg twice a day and injection progesterone 50 mg I/M on an alternate day was started once the endometrium achieved maximal thickness and continued after FET.

IURP preparation and installation

Intrauterine instillation of PRP was performed under all aseptic precautions on day 8 or day 9 of the cycle. A volume of 15 ml of peripheral venous blood was drawn in a syringe containing 5 ml of Acid Citrate A Anticoagulant solution and centrifuged immediately at 200 g for 10 min to separate the red blood cells. The plasma and buffy coat obtained were centrifuged again at 500 g for 8 min to obtain 0.3–0.4 mL of PRP which was infused into the uterine cavity with the help of an embryo transfer (ET) catheter under ultrasound guidance. An ultrasound was performed 3–4 days later and the endometrial thickness and character was assessed. FET was performed in the patients who achieved an endometrial thickness of more than 7 mm.

Study type: Interventional.

Study Design: Retrospective analysis of data, pilot study; Intervention Model: Parallel Assignment. Successful clinical pregnancy rates were defined as the number of pregnancies (diagnosed by ultrasound visualization of one or more gestational sacs) per 100 initiated ET cycles. Statistics: “N-1” Chi-squared test and Student's t-test were employed to compare proportions and means, respectively. Microsoft Excel 2010 software was used in data analysis.


  Results Top


The mean age, body mass index (BMI), and anti-mullerian hormone of the study population (control vs. test) were 33.4 versus 33.5 years, 25.2 versus 24.5 kg/m2 and 2.9 versus 2.6 ng/mL, respectively and there was no difference between cases and controls. Overall 42.8% became pregnant in the control group and 47.6% in the intervention group. Although there seemed to be an increase in the pregnancy rates with IUPRP, this was not statistically significant. A PR of 48% was observed in patients with secondary infertility while patients of primary infertility had a PR of 38% [Table 2] and [Table 3]. Pregnancy rate in primary infertility patients following PRP treatment was lower when compared to untreated primary infertility patients (38% and 48%, respectively), while pregnancy rate improved (from 38% to 54%) with PRP treatment in secondary infertility patients [Figure 1].
Table 2: General characteristics and in vitro fertilisation outcome of patients with primary infertility

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Table 3: General characteristics and in vitro fertilization outcome of patients with secondary infertility

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Figure 1: Clinical pregnancy rates in patients with primary and secondary infertility post IUPRP

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Statistics

“N-1” Chi-squared test was employed as recommended by Campbell (2007) and Richardson (2011). The confidence interval was calculated according to the recommended method given by Altman et al. (2000). The significance of a mean difference between two samples of continuous data was analyzed by t-test which uses the probabilities from the student t distribution (Welch, B. L. (1947), “The generalization of” student's “problem when several different population variances are involved.” Biometrika 34: 28–35). Microsoft Excel 2010 software was used in data processing and analysis.


  Discussion Top


Successful implantation is a well-orchestrated event requiring the presence of a healthy embryo, a receptive endometrium, appropriate embryo – endometrial cross-talk, and adequate maternal immune protection.[1] Implantation failure can occur during any of the three stages of implantation, i.e., apposition, adhesion, and invasion. Most failures are attributed to either embryo aneuploidy, altered endometrial receptivity, or dysregulation of the immune system through identification of the exact cause remains elusive.[9] Various tools have been employed to improve the implantation rates in patients with previous FET failures, for example, blastocyst transfer, offering PGT-A, endometrial scratching, transcriptomics to assess WOI with the help of ERA test, sequential transfer, and use of immunomodulators.[1]

Despite advances in the field of reproductive medicine implantation failure remains a major challenge.[10] In a normal menstrual cycle in human, endometrium becomes receptive during the window of implantation which in natural cycle is in the mid-secretory phase around days 19–23. During this period, cytokines, growth factors, prostaglandins, and adhesion molecules are expressed, and inconsistency of these proteins could impair implantation. Various studies have investigated that expression of growth factors in the endometrium of women with RIF is less than normal fertile women. According to this hypothesis, local infusion of PRP that contains several growth factors and cytokines may improve endometrial receptivity and implantation.[5],[6],[7],[8],[11]

PRP is made from autologous blood and has a platelet concentration which is about 4–5 times more than the circulating blood. PRP is prepared from fresh whole blood and contains several growth factors and cytokines including fibroblast growth factor, PDGF, VEGF, TGF, insulin-like growth factor I, II, connective tissue growth factor, and interleukin 8. PRP has been investigated as a therapeutic approach for several medical disorders including nerve injury, ocular epithelial defects, alopecia, cardiac muscle injury, osteoarthritis, and tendinitis. Despite the wide use of PRP in several fields in medicine, its use in the field of reproductive medicine is limited.[3] There is now upcoming evidence which states that PRP and its biostimulation effects on the endometrial microvasculature seem to be beneficial to patients with refractory endometrium, providing an increase in endometrial receptivity and a consequent increase in implantation rates. Earliest reports of the use of PRP in reproductive medicine has been from China, where Chang et al. 2015 used PRP to improve endometrial thickness in patients with thin endometrium.[4] This was followed by a few studies done to evaluate the effect of PRP in refractory endometrium and recurrent implantation failures.[5],[6],[7],[8],[11] Aghajanova et al. 2016[7] evaluated an in vitro model of activated PRP for endometrial regeneration. Activated PRP promoted the migration of human primary endometrial epithelial cells, endometrial stromal fibroblasts, endometrial mesenchymal stem cells (MSC), and bone marrow-derived MSC These data provide an initial ex vivo proof of principle for the use of autologous PRP to promote endometrial regeneration in Asherman's syndrome and a thin endometrial lining. Tandulwadkar et al. 2017[8] suggested that the use of autologous PRP holds promise in the treatment of women with suboptimal ET and vascularity for ET. The mean pre-PRP endometrial thickness (ET) was 5 mm which significantly increased to 7.22 mm post-PRP. There was also a significant increase in vascularity assessed by the number of vascular signals seen on Power Doppler reaching the zones 3 and 4 of the endometrium.

Nazari et al. 2016[5] enrolled 20 participants with a history of RIF to evaluate the effectiveness of PRP in improving the pregnancy rate in RIF patients. The inclusion criteria were being younger than 40 years and having a BMI below 30 kg/m2. They reported that 18 of the 20 participants (90%) became pregnant. Sixteen clinical pregnancies were recorded, and their pregnancies were ongoing at the time of the study. They concluded that PRP was effective in improving pregnancy outcomes in RIF patients.

Our study, in contrast, could not find an improved implantation or PR in patients undergoing FET after a first failed transfer in an HRT cycle. In our study, we found a PR of 42.8% in the control group and 47.6% in the intervention group. Although there seemed to be a slight increase in the pregnancy rates with IUPRP, this was not statistically significant. A PR of 48% was observed in patients with secondary infertility while patients of primary infertility had a PR of 38%. Pregnancy rate in primary infertility patients following PRP treatment was lower when compared to untreated primary infertility patients (38% and 48%, respectively), while pregnancy rate improved (from 38% to 54%) with PRP treatment in secondary infertility patients, but it is difficult to ascertain whether this increase is due to PRP effect alone as patients with secondary infertility are known to have better results in IVF. Moreover, the small patient number in our study could have been the reason for the observed difference in results from other studies. Further randomized controlled trials are needed to test the hypothesis that IUPRP can improve endometrial receptivity. Till such time PRP treatment should be undertaken with meticulous patient selection.


  Conclusion Top


Intrauterine PRP infusion does not significantly improve the implantation rates in patients undergoing FET who have had one previous FET failure.

IUPRP seems to be more beneficial in patients with secondary infertility than primary infertility though we need a larger sample size to draw any conclusive results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rinehart J. Recurrent implantation failure: Definition. J Assist Reprod Genet 2007;24:284-7.  Back to cited text no. 1
    
2.
Coughlan C, Ledger W, Wang Q, Liu F, Demirol A, Gurgan T, et al. Recurrent implantation failure: Definition and management. Reprod Biomed Online 2014;28:14-38.  Back to cited text no. 2
    
3.
Lee JW, Kwon OH, Kim TK, Cho YK, Choi KY, Chung HY, et al. Platelet-rich plasma: Quantitative assessment of growth factor levels and comparative analysis of activated and inactivated groups. Arch Plast Surg 2013;40:530-5.  Back to cited text no. 3
    
4.
Chang Y, Li J, Chen Y, Wei L, Yang X, Shi Y, et al. Autologous platelet-rich plasma promotes endometrial growth and improves pregnancy outcome during in vitro fertilization. Int J Clin Exp Med 2015;8:1286-90.  Back to cited text no. 4
    
5.
Nazari L, Salehpour S, Hoseini S, Zadehmodarres S, Ajori L. Effects of autologous platelet-rich plasma on implantation and pregnancy in repeated implantation failure: A pilot study. Int J Reprod Biomed (Yazd) 2016;14:625-8.  Back to cited text no. 5
    
6.
Farimani M, Poorolajal J, Rabiee S, Bahmanzadeh M. Successful pregnancy and live birth after intrauterine administration of autologous platelet-rich plasma in a woman with recurrent implantation failure: A case report. Int J Reprod Biomed (Yazd) 2017;15:803-6.  Back to cited text no. 6
    
7.
Aghajanova L, Houshdaran S, Balayan S, Irwin J, Huddlestom H, Giudice L. Platelets for endometrial regeneration: A novel approach. Fertil Steril 2016;106:e82.  Back to cited text no. 7
    
8.
Tandulwadkar SR, Naralkar MV, Surana AD, Selvakarthick M, Kharat AH. Autologous intrauterine platelet-rich plasma instillation for suboptimal endometrium in frozen embryo transfer cycles: A pilot study. J Hum Reprod Sci 2017;10:208-12.  Back to cited text no. 8
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9.
Coulam CB. Implantation failure and immunotherapy. Hum Reprod 1995;10:1338-40.  Back to cited text no. 9
    
10.
Simon A, Laufer N. Repeated implantation failure: Clinical approach. Fertil Steril 2012;97:1039-43.  Back to cited text no. 10
    
11.
Molina A, Sánchez J, Sánchez W, Vielma V. Platelet-rich plasma as an adjuvant in the endometrial preparation of patients with refractory endometrium. JBRA Assist Reprod 2018;22:42-8.  Back to cited text no. 11
    


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    Tables

  [Table 1], [Table 2], [Table 3]



 

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