Platelet-rich plasma (PRP) has become popular as a non operative treatment option for a broad spectrum of medical disorders. There are reasonable amount of data which warrant continued research in PRP but currently its role in clinical practice is not completely defined. Prior to its use, special consent is required after an honest and open discussion with the patient as well controlled human studies are lacking

1. PRP

2. ▸ Dr Shivani Sachdev Gour
▸ MD DNB MRCOG (UK)
▸ Consultant Fertility Specialist
Gynaecologist
▸ SCI IVF Centre
New Delhi and Noida
▸ DR Nupur Garg
▸ MS, FNB
Consultant Fertility
Specialist Gynaecologist
SCI IVF Centre
New Delhi and Noida

3. INTRODUCTION
▸ Platelet-rich plasma (PRP) has become popular as a non
operative treatment option for a broad spectrum of medical
disorders
▸ Based on the theory of natural healing where, in response to
the tissue injury platelets are delivered to the injured area.
▸ Platelets promote healing and attract stem cells to the site of
the injury
3

4. TYPES
▸ 4 types
▸ Platelet Rich plasma (liquid form)
▸ Platelet Rich Leucocyte Rich (liquid form)
▸ Platelet Rich with fibrin (solid form)
▸ Platelet rich Leucocyte rich with fibrin (solid form)
▸ Here discussion is for first type platelet rich (leucocyte
poor)
4

5. Definition of PRP
▸ PRP is defined as a plasma fraction of autologous blood with the
concentration of platelets 4-5 times above normal
▸ Release granules containing growth factors, such as TGF-β, PDGF, IGF,
VEGF, EGF and FGF-2
▸ Also antiinflammatory and pro-inflammatory interleukins, IL-4, IL-8, IL-13,
IL-17
▸ In addition, there are proteins with antibacterial and fungicidal actions
▸ These promote tissue regeneration and healing
5

6. 6

7. SAFETY
▸ PRP is prepared from autologous blood, theoretically there are
minimal risks for disease transmission, immunogenic reactions
and cancers
▸ Longterm clinical experience on the application of PRP in the
oral maxillary ,dermatology field thousands of patients have
received this therapy so far, the use of PRP is considered safe
7

8. ROLE OF PRP IN REPRODUCTIVE MEDICINE
▸ Refractory Thin Endometrium
▸ RIF
▸ POR/POF
8

9. Thin Endometrium
▸ Endometrial thickness (Eth)—one of the most frequently employed
indirect predictors of Endometrial receptivity
▸ Thin endometrium in assisted reproduction is often defined as
endometrial thickness <7 mm or <8 mm.(Friedler 1996)
▸ The prevalence of an ‘abnormal’ or ‘thin’ endometrium varies with age
▸ 5% of younger women
▸ 25% in older patients (Sher et al., 1991).
9

10. Thin Endometrium
10
▸ Specific cut-off values not been identified.
Min ET Study
4-5mm Check and Cohen, 2011
6mm Alamet al., 1993
7mm Friedler et al., 1996
Optimum ET Study
9mm Zhang et al., 2005; Richter et al.,
2007)
10mm Rinaldi et al., 1996
9-14mm Check et al., 2004

11. Why is Endometrial Thickness
Important?
11

12. ▸ Endometrial thickness and pregnancy rates after IVF: a systematic review and meta-
analysis :Annemieke Kasius. Human Reproduction Update, Vol.20, No.4 pp. 530–541, 2014

13. 13
ET mm LBR %
>8 33.7
7-7.9 25.5
6-6.9 24.6
5-5.9 18.1
ET mm LBR %
>8 28.4
7-7.9 27.4
6-6.9 23.7
5-5.9 15
4-4.9 21.2
In Fresh IVF-ET CPR and LBR decreased
and Preg Loss increased (P = 0.01) with each
mm decline in ET below 8 mm
In FET cycles, CPR (P = 0.007) and LBR decreased
with each mm decline in ET below 7 mm, with no
significant difference in pregnancy loss rates.

14. The entire range of trigger-day endometrial thickness values in fresh in vitro
fertilization cycles is in direct independent correlation with the live birth rate
M. Simeonov RBM ONLINE 2020
▸ A cohort of all IVF fresh day 3 ETs in patients age ≤42 in a single center between
2009-2017 were studied
▸ Results: 5133 cycles were included. LBRs were as follows:
14
ET mm LBR %
>16 34.21
13-15 25.62
10-12 23.44
7-9 17.98
<6 11.2

15. 15
Thin
Endometrium
High
Impedence
Blood Flow
Impaired
glandular
epithelium
growth
Decreased
VEGF
expression
Poor
Vascular
Development
Pathophysiologic features of ‘‘thin’’ endometrium. Ichiro Miwa Fert Stert 2009
Pathology of
Thin
Endometrium

16. Mechanisms of action
of PRP in Thin
Endometrium
▸ High concentration of growth factors in
PRP
▸ They are mitogenic and angiogenic
▸ Cytokines promote receptivity
▸ Have anti-microbial, anti-inflammatory
properties
▸ Promote regenerative process
16
Endometrial
Growth
Endometrial
cell Migration
Proliferation
Differentiation
Neo
Angiogenesis

17. 17

18. PRP Preparation
▸ Venous blood (15–50 mL) is drawn from the patient’s arm in
anticoagulant-containing tubes
▸ The recommended temperature during processing is 21˚C–24˚C to
prevent platelet activation during centrifugation of the blood
▸ The blood is centrifuged at 1,200 rpm for 12 minutes
▸ The blood separates into three layers: an upper layer that contains
platelets and white blood cells, an intermediate thin layer (the buffy coat)
that is rich in white blood cells, and a bottom layer that contains red
blood cells;
18

19. PRP Preparation
▸ The upper and intermediate buffy layers are transferred to an
empty sterile tube. The plasma is centrifuged again at 3,300
rpm for 7 minutes to help with the formation of soft pellets
(erythrocytes and platelets) at the bottom of the tube;
▸ The upper two-thirds of the plasma is discarded because it is
platelet-poor plasma
19

20. PRP Preparation
▸ Pellets are homogenized in the lower third (5
mL) of the plasma to create the PRP
▸ The PRP is now readyfor injection.
Approximately 30 mL of venous blood yields 3–5
mL of PRP
20

21. 21

22. 22
classification)

23. What is Ideal Platelet-rich Plasma?
▸ The general consensus among most studies have suggested
that effective concentration of platelet in PRP should be a
minimum increase of 5 times the normal concentration of
platelets
▸ Concentration more than this has not shown any added
benefits .
23

24. PROBLEM
▸ What is the ideal concentration of PRP?
▸ Which technique is better as several techniques and
commercial products are used for PRP preparation?
▸ Which PRP is better as each commercial technique leads to
formation of different product?
▸ Each has different biology and efficacy?
24

25. PRP in Thin Endo-Prerequisites
▸ Should be negative for hysteroscopic endometrial
pathology
▸ Should be negative for bacteriologic screening.
▸ poor endometrial growth (<6 mm)
25

26. Process of PRP in Thin endometrium
▸ Women with poor endometrial response to standard (HRT) (ET < 7 mm) on
10th- 13th day of the cycle in a frozen-thawed embryo transfer (FET).
▸ 0.5-1 cc of PRP infused into the uterine cavity on the10- 13th day
▸ If endometrial thickness failed to increase after 48 h, PRP infusion was
repeated in the same cycle.
▸ When the endometrium thickness reached ≥7 mm, embryo transfer was
done
26

27. 27
▸ Studied the role of PRP in the regeneration of the endometrium
after ethanol-induced damage.
▸ Results: intrauterine administration of autologous PRP
stimulated and accelerated regeneration of the endometrium,
as well as decreased fibrosis

28. 28

29. 29
▸ 33,Patients with H/O RIF ,In Fresh IVF cycle underwent Intrauterine PRP instillation and s.c
inection of G-CSF, 48hours prior to ET.G-CSF was repeated weekly. If pregnancy occured, G-
CSF was maintained until the 12th gestation week.
▸ Control group: n=33patients in their first IVF/ICSI cycle attempt(without PRP or G-CSF).
▸ Result: There were no significant differences between the PRIMER and Control groups
regarding implantation, pregnancy, ongoing pregnancy or live birth rates
▸ PRIMER enabled patients with RIF to reach similar ongoing pregnancy and live birth rates to
those patients who had their first IVF/ICSI cycle attempt

30. PRP in repeated implantation failure
30

31. ▸ Of the 64 patients that received a frozen
embryo transfer, endometrial vascularity
increased in all patients.
▸ 60.1% (39/64) reported chemical
pregnancy with an ongoing pregnancy
rate of 45.3% (26/64).
▸ Average mean lining thickness before
PRP infusion was 5 mm and 7.22 mm after
PRP infusion
31

32. ▸ 2 cases 37 yr old and 40 yr old P0A1 and P0A2 ,of moderate Ashermans underwent
PRP post hysteroscopy after adhesiolysis followed by estrogen therapy 4mg/day for
1 month and antibiotics for 7 days and intrauterine balloon placement for 7days
▸ 1 case reported spontaneous conception other conceived after IVF DCDA
sponaneous reduction to singleton. Both were ongoing pregnancy, third trimester at
the time of writing the report
32

33. The success of PRP depends on the presence of endometrial
differentiated (resident) and progenitor cells from which the cell
layer will regenerate.
▸ The application of PRP on unhealthy scarred tissue with no
viable endometrial cells is futile, thus very limited success is
guaranteed, particularly in severe cases
33

34. POF
▸ PRP in premature ovarian failure
▸ Introduction of isolated growth factor-bearing platelets
directly into the ovaries trigger a resurgence in oocyte
production, injected into the ovary under ultrasound guidance,
still being investigated in trials
34

35. OVARIAN REJUVENATION
▸ Pantos et al. at the annual ESHRE conference held in 2016 in Helsinki,
Finland, introduced this modality {ovarian rejuvenation}.
▸ They injected PRP in eight perimenopausal/ POF women with poor ovarian
reserve. They found successful ovarian rejuvenation 1–3 months after PRP
treatment.
▸ All cases underwent natural IVF cycles with follicles of 15.20±2.05 mm in
diameter, the resulting oocytes were inseminated by ICSI and all resulting
embryos were cryopreserved.
35

36. ▸ A 37-year-old woman with POI with secondary amenorrhea for 6 months. AMH (<0.02 ng/mL) and an elevated
serumlevel of FSH (63.65 mIU/mL).
▸ A single dose of autologous PRP 4 ml (From 40 ml blood) in combination with gonadotropin (150IU rFSH/75 IU
rLH) 1 ml was directly injected into the stroma of bilateral ovaries via vaginal sonographic guidance.
▸ Following the treatment, this patient received IVF during the successive months. Following embryo culture,
three cleavage-stage embryos were transferred, leading to a successful pregnancy, which later resulted in
the live birth of twins.
36

37. ▸ This report presents the case of awoman aged 40who has experienced
prematuremenopause from the age of 35.
▸ Six weeks following the intraovarian autologous platelet-rich plasma
injection, a significant reduction in the patient’s follicle-stimulating
hormone (FSH) levels were noted.
▸ A natural in-vitro fertilization cycle led to a biochemical pregnancy,
resulting in a spontaneous abortion at the 5th week of pregnancy.
37

38. ▸ In-vitro culture of preantral follicles is an alternative and safe fertility
preservation approach for both reproductive-age women and prepubertal
girls without hormonal stimulation or risk of reintroducing cancer cells
▸ In this study ovarian tissues were obtained from three females under 35
years of age and preantral follicles isolated and cultured in media
supplemented with PRP
▸ Survival and growth of follicles was found to be significantly higher
38

39. ▸ Autograft of frozen-thawed ovarian tissue for restoration of ovarian function and fertility is
considered the an important method of fertility preservation
▸ The main problem is that the implant undergoes ischemia until neoangiogenesis is restored,
resulting in significant follicular loss. Only 22 Live birth in 12 women have beeen reported
▸ In this case report both thawed ovarian tissue as practiced pockets on the rear side of the
broad ligament were impregnated with PRP
▸ Results: successful pregnancy and birth after the first stimulation cycle
39

40. 40

41. 41
▸ Successful pregnancies have been described in the setting of treated
Asherman or thin lining after PRP infusion even without increased
endometrial thickness, suggesting that PRP might not only improve
proliferation of endometrial cells, but could probably modulate endometrial
functionality and receptivity on molecular level
▸ The treatment is appealing to patients for multiple reasons (safe, easy, and
relatively cheap) and often is the last option before giving up and moving to
alternative option such as gestational carrier or adoption
▸ Although comparatively less data available in patients of POF

42. Critical Appraisal of
PRP
42

43. Studies on PRP
43

44. 44

45. CFAS RECOMMENDATION
▸ In patients with thin endometrium undergoing embryo transfer
cycles, guidelines suggest against the use of platelet-rich
plasma to improve pregnancy rates
▸ Reason: Only case reports and case series are in the literature,
with no controlled studies reported.
▸ Further research to evaluate the potential risks and benefits
45

46. 46
Use of PRP is not approved by the U.S. Food and
Drug Administration and is therefore an off-label
use. Currently, the use of PRP in reproductive
medicine should be considered experimental

47. Platelet-rich plasma another add-on treatment getting out of
hand? How can clinicians preserve the best interest of their
patients?Bulent Urman Human Reproduction Nov 2019
▸ The only evidence for PRP comes from small scale and mostly
before and after studies
▸ PRP has not been subjected to a rigorous clinical trial.
▸ We should be extremely cautious prior to implementing PRP
on a widescale and should await the results of well-designed
studies.
47

48. 48

49. Conclusion-Honest Balanced
Information
▸ We should practice combined approach to a complex clinical
situation such as thin endometrium, RIF.
▸ Hysteroscopic evaluation should be a priority.
▸ If treatments to increase endometrial growth fails additional
methods such as PRP can be offered to the patient
▸ Take informed consent with benefit/ risks and counselling of
the patient explaining the research nature of the treatment
49

50. ROLE OF PRP IN
GYNAECOLOGY

51. PRP in Gynaecology and Obstetrics
▸ Skin lesions and wound healing- scars (LSCS
scar,gynecological surgery)-reduction in
redness,edema,pain,faster wound healing
▸ Cervical ectopy- cervical erosion healing re-
epithelisation is faster in PRP compared to laser.
Side effects like bleeding and discharege lower in
PRP
51

52. PRP in Gynaecology and Obstetrics
▸ Vulvar dystrophy -resistant to steroids
▸ Reconstructive surgery for vulvar cancer- platelet gel
application in women after radical surgery, prevents wound
breakdown after surgery
▸ Genital fistulae
▸ Genital prolapse and urinary incontinence -causes rapid
remodelling and connective tissue growth after vaginal
surgery
52

53. PRP in Ovarian Torsion
▸ Ovarian torsion- In Animal model
Intraperitoneal PRP administered 30 minutes
prior to ischemia led to lower oxidative stress
levels, histopathological changes, and
reperfusion injuries
53

54. PRP in Aesthetic Gynaecology
▸ Breast reconstruction- patients treated with PRP
added to the autologous fat grafts showed a 69%
maintenance rate of the restored contour and of
three-dimensional volume after 1 year, whereas the
patients in the control group showed a 39%
maintenance rate
54

55. PRP in Female Sexual Dysfunction
▸ Vaginal rejuvenation and O-shot therapy- helps improve both
urinary incontinence and sexual dysfunction through using a
woman’s own growth factors
▸ The PRP is injected into specific areas of the vagina with the
aid of local anesthetic cream.
▸ PRP activates tissue regeneration, and enhances sexual
response, decreases dyspareunia, and increases natural
lubrication
55

56. Vaginal Rejuvenation
▸ Regeneration of vaginal mucosa, muscles, and skin
▸ Skin becomes thicker and firmer, making the vagina look
much more youthful
▸ The ligaments and muscles supporting the urethra become
stronger, alleviating urinary incontinence
56

57. PRP IN PROM
▸ PRP was tried in an in vitro model to evaluate the ability of PRP to seal
iatrogenic fetal membrane defects
▸ PRP plug persisted for nearly 2 months in an amniotic fluid
environment.
▸ It also provided waterproof sealing of iatrogenic defects in the
amnion and chorion.
▸ Moreover, PRP stimulates cell growth and proliferation, and may
thereby enhance the membrane-healing response
57

58. CONCLUSION
▸ PRP is very promising futuristic therapy. It is a vehicle to deliver
large amount of important growth factors, which are
biologically active to the site of action
▸ It is very simple and easy to use, easily available, uses patient
own blood (autologous), potential cost-effective and
considered very safe therapy.
▸ But despite the promising results of several animal studies,
well-controlled human studies are lacking
58

59. CONCLUSION
There are reasonable amount of data which warrant
continued research in PRP but currently its role in
clinical practice is not completely defined. Prior to its
use, special consent is required after an honest and
open discussion with the patient as well controlled
human studies are lacking
59

60. 60
Thank
You