|Year : 2019 | Volume
| Issue : 2 | Page : 62-65
Comparing the effectiveness of intrauterine infusion of platelet-rich plasma and granulocyte-Colony-stimulating factor in frozen embryo transfer cycles
Priya Selvaraj, Kamala Selvaraj, Hamini Chandrasekar, Lakshaya Sairam
GG Hospital Fertility and Women's Speciality Centre, Chennai, Tamil Nadu, India
|Date of Submission||05-Nov-2019|
|Date of Acceptance||14-Nov-2019|
|Date of Web Publication||31-Jan-2020|
Dr. Priya Selvaraj
GG Hospital, Fertility and Women's Speciality Centre, Chennai - 600 034, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: The aim of the study was to compare the effectiveness of intrauterine perfusion of platelet-rich plasma (PRP) and granulocyte-colony-stimulating factor (G-CSF) in improving assisted reproductive technology (ART) outcomes in women with thin endometrium and recurrent implantation failure (RIF) undergoing frozen embryo transfer (FET).
Materials and Methods: The study was conducted at GG Hospital, Fertility and Women's Speciality Centre, Chennai, India, between March 2016 and September 2019. The study group comprised of 132 demographically identical women with RIF and thin endometrium undergoing FETs. The mean age of the participants in both the groups was 33.18 ± 4.30 and 32.5 ± 5.02, respectively. These women were randomly divided into PRP Group A (n = 56) and G-CSF Group B (n = 76). Both the groups were initiated with the conventional preparation for FET using estradiol valerate and micronized progesterone along with a trigger (10,000 IU of human chrionic gonadotropins (HCG)). Intrauterine PRP and G-CSF were then administered for those patients with thin endometrium (≤0.8 cm) on days 16 and 18, and sequential embryo transfers were performed as day 3 embryos along day 5 blastocyst.
Results: The average endometrial thickness before the infusion of PRP and G-CSF was 0.67 ± 0.09 and 0.70 ± 0.08, whereas after the infusion, it improved to 0.78 ± 0.14 and 0.75 ± 0.06, respectively. P value between Groups A and B was 0.0968 and hence statistically not significant, indicating similar improvement by both the methods. P value for implantation rate, clinical pregnancy rate, live birth rate (LBR), and miscarriage rate was 0.182, 0.695, 0.287, and 0.270, respectively. It was found that there is no statistically significant difference in ART outcomes in both the PRP and G-CSF groups.
Conclusion: Intrauterine infusion of PRP and G-CSF was beneficial in improving LBR in RIF with thin endometrium, both being statistically comparable. There were no differences to show superior of one over the other.
Keywords: Frozen embryo transfer, granulocyte-colony-stimulating factor, platelet-rich plasma, recurrent implantation failure, thin endometrium
|How to cite this article:|
Selvaraj P, Selvaraj K, Chandrasekar H, Sairam L. Comparing the effectiveness of intrauterine infusion of platelet-rich plasma and granulocyte-Colony-stimulating factor in frozen embryo transfer cycles. Onco Fertil J 2019;2:62-5
|How to cite this URL:|
Selvaraj P, Selvaraj K, Chandrasekar H, Sairam L. Comparing the effectiveness of intrauterine infusion of platelet-rich plasma and granulocyte-Colony-stimulating factor in frozen embryo transfer cycles. Onco Fertil J [serial online] 2019 [cited 2022 Sep 28];2:62-5. Available from: https://www.tofjonline.org/text.asp?2019/2/2/62/277442
| Introduction|| |
Assisted reproduction is a rapidly evolving field with introduction of newer modalities at a rapid pace with an aim to increase clinical pregnancy rate (CPR). One challenging area is recurrent implantation failure (RIF) in thin endometrium.
There have been innovations in asserting normalcy of transferred embryos by preimplantation genetic testing, while molecular arrays have been introduced to evaluate the endometrium. However, the interaction between the endometrium and embryo remains ambiguous and truly an enigma. A broad range of research is being carried out to study the circumstances that influence endometrial receptivity and the means to assess and improve the same. During the uterine cycle, the developing follicles secrete increased amounts of estradiol which leads to the endometrial glandular changes in the proliferative phase. This is followed by decidualization in which the decidua secretes cytokines which in turn controls the invasion of trophoblast. Several studies cite that endometrial vascularity plays an inevitable role in the process of implantation. Likewise, endometrial thickness is also considered to be a necessary factor. Thin endometrium is one of the major challenges which are being faced by clinicians and embryologists. There are several treatments and that are being carried out all over the globe including the use of stem cells to overcome the challenge in order to achieve successful implantation. Granulocyte-colony-stimulating factor (G-CSF) and platelet-rich plasma (PRP) are known in this regard, which concentrate on the improvisation of endometrial thickness.
G-CSF is a glycoprotein belonging to the growth factor family. It was first successfully administered by Gleicher et al. for treating an unresponsive endometrium. Studies have proved that G-CSF is present in the female reproductive system and known to increase the cyclic adenosine monophosphate-mediated decidualization of human endometrial stromal cells in an autocrine or paracrine pattern.
PRP is another popular treatment. Platelets are one of the blood components that play an important role in hemostasis. In the event of healing, growth factors, chemokines, and cytokines are secreted from the α-granules inside platelets. The various proteins which are secreted have paracrine effects on endothelial cells, fibroblasts, cell migration, and cell proliferation. There are four types of platelet preparations, leukocyte-poor or pure PRP, leukocyte PRP (L-PRP), pure platelet-rich fibrin clot, and leukocyte platelet-rich fibrin clot. The present study is based on the comparison between L-PRP and G-CSF treatments and their outcomes.
| Materials and Methods|| |
The present study was conducted at GG Hospital, Fertility and Women's Speciality Centre, Chennai, India, between March 2016 and September 2019 on 132 demographically identical women undergoing frozen embryo transfers (FETs). These women were randomly divided into PRP Group A (n = 56) and G-CSF Group B (n = 76). Both the groups were initiated with the conventional preparation for FET using incremental doses of estradiol valerate 2 mg from day 2/3 of the menstrual cycle, followed by mid-cycle evaluation of endometrial thickness on day 12/13. Intrauterine PRP and G-CSF were then administered for those patients with thin endometrium (≤0.8 cm) on days 16 and 18, postinitiation of micronized progesterone (1200 mg/day) from day 16 along with a trigger 10,000 IU of HCG. Improvement in the endometrium thickness was assessed using ultrasonography.
Preparation of platelet-rich plasma infusion
For the patients those who belonged to Group A, on the 10th day of hormone replacement therapy cycle, 15 ml of venous blood was drawn from the syringe prefilled with 5 ml of anticoagulant citrate dextrose solution (ACD-A, Becton Drive (BD), Franklin Lakes, USA) and centrifuged immediately at 200 g for 10 min. The blood was then segregated into three layers: the bottom layer consisted of red blood cells, cellular plasma in the supernatant, and a buffy coat layer separating the red blood cell layer and the supernatant. The plasma layer and buffy coat layer were collected and recentrifuged at 500 g for 10 min. The resulting pellet of platelets was gently aspirated with 1 ml of supernatant. About 0.5–0.7 ml of the PRP was loaded in a syringe with air gap. It was then infused into the uterine cavity using a 65-mm intrauterine insemination catheter (Vardhman Medicare, New Delhi, India). The thickness of the endometrium was reassessed after 48 h. Any improvements were noted, and the second infusion was performed 48 h later.
Granulocyte-colony-stimulating factor infusion
Intrauterine instillation of G-CSF 0.3 ml Xgrast - Filgrastim (IP 300 mcg/0.5 ml in prefilled syringe, Gennova biopharmaceuticals, Pune, Maharashtra, India) using an intra uterine insemination (IUI) catheter was given on days 16 and 18. These patients were then evaluated for endometrial thickness before and after embryo transfer.
After completion of both the treatments, frozen sequential transfers were performed in both the groups. The pregnancies were confirmed with serum ß-HCG test, followed by an ultrasound on day 38 to confirm the sac and fetal heartbeat.
| Results|| |
A study population of 132 patients were divided into Group A (PRP, n = 56) and Group B (G-CSF, n = 76). The mean age of Group A and Group B was 33.18 ± 4.30 and 32.5 ± 5.02, respectively. The average endometrial thickness before the infusion of PRP was 0.67 ± 0.09 (cm), and after the infusion, it improved to 0.78 ± 0.14 (cm), whereas the endometrial thickness before the infusion of G-CSF was 0.70 ± 0.08 (cm), and postinfusion, it was improved to 0.75 ± 0.06 (cm). The P value for both PRP and G-CSF was <0.0001, which is highly significant, suggesting the improvement in endometrial thickness by both the methods. However, the postendometrial thickness compared between Group A and Group B was nonsignificant (P = 0.0968). The difference in endometrial thickness is shown in [Graph 1] and [Table 1]. The implantation rate in patients infused with PRP was noted to be 30.8%, and in patients infused with G-CSF, it was 23.38% which was not significant (P = 0.182). The CPR in Group A was 48.2% and Group B was 44.7% with P = 0.695 which is also statistically not significant. The rate of live birth showed no significant difference (P = 0.287) in patients who were administered with PRP and G-CSF with a rate of 70.37% and 82.35%, respectively. The miscarriage rate in the PRP group was noted to be 29.62%, and in G-CSF, it was 17.64%. The P value for miscarriage rate was 0.27 which showed no significant difference. The pregnancy outcomes with statistical values which were analyzed in SPSS software (12.0) are elucidated in [Table 2] and [Graph 2]. Although CPR and live birth rate (LBR) were found higher in the G-CSF-treated group, statistically there is no significant difference observed between both the treatment methods. Hence, both the methods seem to be equally good in improving ART outcomes in women with thin endometrium and recurrent implantation failure (RIF).
| Discussion|| |
This comparative study postulates that the thickness of the endometrium improved relatively better with PRP treatment when compared to that of G-CSF. However, a higher miscarriage rate was evident in patients who were infused with L-PRP, followed by a FET. The interventional prospective cohort study conducted by Kim et al. comprised patients who had a history of two or more in vitro fertilization cycles and thin endometrium. The patients were infused with autologous PRP, and the implantation, CPR, and LBR reached up to 12.7%, 30%, and 20%, respectively. Another comparative study conducted between PRP and G-CSF by Vora et al. exhibits a statistically significant result on endometrium thickness. However, the P values of chemical rate (P = 0.777) and CPR (P = 0.3768) were not significant. Hence, the injection G-CSF was superior in action as compared to PRP in increasing the endometrial thickness. They concurred that the improvement in the thickness of the endometrium is due to the various cytokines and growth factors such as transforming growth factor-β, platelet-derived growth factor, and interleukin-8. It also showed that a complex molecular process including endometrial integrins, adhesion molecules, extracellular matrix molecules, growth factors, and ion channels is essential for successful implantation.
Mehrafza et al. in their study observed that the chemical rate and CPR were 43.3% and 40.3% in the PRP group and 26.8% and 21.4% in the G-CSF group. The P values were 0.057 and 0.025, respectively. It was concluded that PRP method may be beneficial for patients with RIF. Kim et al. observed the endometrial receptivity to be controlled by dynamic and precise molecular and cellular events of cytokines, homeobox transcription factors, and genes. Among the numerous cytokines, leukemia inhibitory factor has been found to have a strong role in uterine preparation and embryo attachment. On the other hand, studies showed that G-CSF is a hematopoietic lineage-specific cytokine produced by cells of the bone marrow, stromal cells, macrophages, fibroblasts, endothelial cells, and monocytes. Its function was found to be proliferation and differentiation of neutrophils in the bone marrow and control their release to the bloodstream. A study conducted by Tanha et al. showed that the mechanism of G-CSF may involve the activation of some immunological factors which are correlated with implantation.
In our study, CPR and LBR between Group A and Group B were statistically nonsignificant, due to the smaller sample size. G-CSF was found to be better in providing CPR and LBR when compared to that of the PRP group. It is suggested that a more randomized study should be conducted with larger number of patients to confirm the effect of PRP and G-CSF in ART outcomes in FET cycles.
| Conclusion|| |
In our study, the use of PRP and G-CSF in individuals who had failed previous embryo transfer cycles using only hormone replacement therapy did exhibit improved outcomes. Although statistically the results were not significant, the use of either modality of treatment tends to increase the pregnancy rates in patients with thin endometrium and RIF.
We thank Ms. Suguna Balakrishnan, HR Department, GG Hospital, Fertility and Women's Speciality Centre, for her valuable inputs in constructing the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jain S, Mahey R, Malhotra N, Kalaivani M, Sangeeta P, Bhatt A, et al
. Effect of Intrauterine perfusion of granulocyte colony-stimulating factor on endometrial parameters and in vitro
fertilization outcome in women undergoing in vitro
fertilization/intracytoplasmic sperm injection cycles: A randomized controlled trial. J Hum Reprod Sci 2018;11:254-60.
] [Full text]
Kovacs P, Matyas S, Boda K, Kaali SG. The effect of endometrial thickness on IVF/ICSI outcome. Hum Reprod 2003;18:2337-41.
Gleicher N, Vidali A, Barad DH. Successful treatment of unresponsive thin endometrium. Fertil Steril 2011;95:2123.e13-7.
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.
] [Full text]
Nikita N, Rajesh S, Amit A. Can granulocyte colony stimulating factor infusion further improve the pregnancy rate even with good endometrial thickness in a frozen embryo transfer cycle?. J Reprod Endocrinol Infert 2018;3:27.
Kim H, Shin JE, Koo HS, Kwon H, Choi DH, Kim JH. Effect of autologous platelet-rich plasma treatment on refractory thin endometrium during the frozen embryo transfer cycle: A pilot study. Front Endocrinol (Lausanne) 2019;10:61.
Vora AV, Nadkarni KP, Garasia J, Nadkarni A, Singh PN, Nadkarni VK. Intrauterine platelet rich plasma versus injection G-CSF for treatment of thin endometrium in infertility. Int J Reprod 2019;8:3931-8.
Mehrafza M, Kabodmehri R, Nikpouri Z, Pourseify G, Raoufi A, Eftekhari A, et al
. Comparing the impact of autologous platelet-rich plasma and granulocyte colony stimulating factor on pregnancy outcome in patients with repeated implantation failure. J Reprod Infertil 2019;20:35-41.
Cavalcante MB, Costa Fda S, Barini R, Araujo Júnior E. Granulocyte colony-stimulating factor and reproductive medicine: A review. Iran J Reprod Med 2015;13:195-202.
Davari-Tanha F, Shahrokh Tehraninejad E, Ghazi M, Shahraki Z. The role of G-CSF in recurrent implantation failure: A randomized double blind placebo control trial. Int J Reprod Biomed (Yazd) 2016;14:737-42.
[Table 1], [Table 2]