How is Platelet-rich plasma (PRP) used in In Vitro Fertilization (IVF)?

Platelet-Rich Plasma (PRP) in IVF: Applications and Evidence

Platelet-rich plasma (PRP) is being investigated as an adjunctive therapy in IVF with potential applications for thin endometrium and poor ovarian reserve, but current evidence is of very low certainty and lacks standardization for clinical implementation. 1

Definition and Preparation of PRP

• PRP is an autologous or allogeneic blood derivative containing a supraphysiological concentration of platelets that release growth factors and cytokines from α-granules to promote tissue healing 2
• PRP preparation methods vary widely, leading to inconsistent terminology, product characteristics, and clinical outcomes 3
• Clinical preparations of PRP are poorly standardized, with content, purity, and biological properties varying widely, which impacts clinical efficacy 3

Applications of PRP in IVF

Intrauterine PRP Application

• Intrauterine infusion/injection of PRP before embryo transfer has been investigated to improve endometrial receptivity in women undergoing assisted reproduction 1
• PRP promotes endometrial growth through cell proliferation, neo-angiogenesis, and anti-inflammatory effects to facilitate endometrial receptivity 4
• Intrauterine PRP has shown potential benefits for women with thin endometrium (≤7mm), with case reports showing successful endometrial expansion after PRP infusion 5
• A Cochrane review found very low-certainty evidence about the effect of intrauterine PRP on live birth rates (OR 1.10,95% CI 0.38 to 3.14) and miscarriage rates (OR 0.96,95% CI 0.13 to 7.09) 1

Intraovarian PRP Application

• Intraovarian injection of PRP has been investigated as a potential treatment for women with poor ovarian reserve and premature ovarian insufficiency 6
• In women with primary ovarian insufficiency (POI), intraovarian PRP injection has been reported to increase antral follicle count (AFC) and serum antimullerian hormone (AMH) levels 7
• Very low-certainty evidence exists regarding the effect of intraovarian PRP injection compared with no intervention on ongoing pregnancy (OR 1.09,95% CI 0.33 to 3.63) and clinical pregnancy (OR 0.90,95% CI 0.31 to 2.60) 1

Limitations and Safety Considerations

• Only one of 12 studies in a recent Cochrane review was judged at low risk of bias, with most studies failing to report live birth outcomes 1
• The International Society on Thrombosis and Haemostasis emphasizes that autologous/allogeneic sterile PRP preparations are clinically safe, but proper sterile technique is essential during preparation and application 3
• Intrauterine infusion of PRP may increase the risk of preterm delivery compared with no intervention (OR 8.02,95% CI 1.72 to 37.33), though this is based on limited evidence 1
• Many trials fail to fully define the content, purity, and biological properties of platelet preparations, making it difficult to compare results across studies 3

Current Recommendations

• The American College of Medical Genetics and Genomics (ACMG) has not specifically addressed PRP use in IVF but emphasizes the need for practice guidelines before widespread implementation of any new reproductive technology 3
• The American College of Obstetricians and Gynecologists (ACOG) does not currently recommend routine use of similar adjunctive technologies like PGT-A for IVF in infertile women due to lack of proven efficacy 3
• Clinical trials on PRP in reproductive medicine should be adequately powered and controlled, with clear inclusion/exclusion criteria, standardized assessments, and objectively measured clinical endpoints 3

Clinical Decision-Making Algorithm

1. Consider PRP only for specific IVF challenges:

   • Thin endometrium (<7mm) unresponsive to standard hormone replacement therapy 5
   • Poor ovarian reserve or premature ovarian insufficiency when conventional approaches have failed 7

2. Before proceeding with PRP:

   • Ensure proper informed consent regarding the experimental nature of the treatment 1
   • Verify no contraindications (blood disorders, active infections) 4
   • Discuss the very low certainty of evidence for improved outcomes 1

3. If proceeding with PRP:

   • Use proper sterile technique with standardized preparation methods 3
   • For intrauterine application: infuse 0.5-1ml PRP on day 10 of hormone replacement therapy cycle 5
   • For intraovarian application: perform ultrasound-guided injection directly into ovarian tissue 7
   • Monitor response (endometrial thickness or ovarian parameters) before proceeding with embryo transfer 5

4. Document outcomes to contribute to the evidence base for this emerging therapy 1