Exploring Intraovarian Platelet-Rich Plasma (PRP) Therapy: A New Hope for Polycystic Ovary Syndrome (PCOS) Patients.

A couple visited the In Vitro Fertilization (IVF) Lab in Wardha, where it was detected that they had been suffering from primary infertility from last four years. The age of male and female was 35 years old and 34 years old respectively. Consent was sign by the couple. The female patient underwent two failed intrauterine insemination (IUI) procedures. She was suffering from PCOS from the age of 20, due to which she had a low ovarian reserve and irregular menstrual cycle but did not have any signs of hirsutism and acne. She was on oral contraceptives. The male patient had problem of hypertension. The body mass index of the female and male was 30.86 kg/m² and 28 kg/m², respectively. The report of physical examination showed that all the patterns were between the reference limit. On the basis of the semen analysis report of the male patient, the semen volume was 1.5ml, sperm count was 16 million/ml, abnormal morphology was 96%, motility was 40%, and the normal morphology was 4%. Ultrasound of the female patient was conducted as part of the physical examination, which demonstrated that the hormone levels were unusual with a high AMH level of 1.45 ng/ml, a low AFC level in the right ovary of 0 and a left ovary of 2-3 and follicle-stimulating hormone (FSH) level of 10.99 IU/ml, as shown in Table 1 . Endocrine profile of the female partner A low dose of recombinant FSH was used in combination with human chorionic gonadotropin (hCG), a trigger to prevent ovarian hyperstimulation syndrome (OHSS) due to her PCOS, while trying to maximize egg quality despite ovarian reserve. After 36 hours of triggering, during the ovum pick up (OPU), five oocytes were retrieved [one MI (meta phase I) and four GV (germinal vesicle)]. All were immature and degenerated. The patient was given inositol tablets twice a day and followed a healthy diet along with regular exercises for 6 months. After 6 months, the patient was advised to undergo the intra-ovarian PRP treatment, as PRP helps to rejuvenate the ovaries, improve the egg quality and ovarian response, and help in oocyte maturation. First, the blood plasma was collected by vein puncture in the acid citrate dextrose (ACD) tube (about 10-12 ml). Initially, whole blood was drawn in the ACD tube, which had an anticoagulant in it (sodium citrate). It was collected on the 13 th day of the MC. Then, it was poured into a conical tube and kept for the centrifuge at 1200 rpm for 10 min. The first centrifugation was performed to separate the RBCs and plasma, and a second centrifugation was performed to concentrate platelets. After the first centrifugation, two layers were formed: the upper layer contained WBCs and platelets, and the bottom layer contained RBCs, as shown in Figure 1 . Then, transfer the supernatant containing the PRP into the sterile tube. Then give a second centrifuge for 10 min at 2000 rpm. Three layers were formed after centrifugation: Plasma is separated from the blood after centrifugation (yellowish part contains the platelet-rich plasma, and the dark red part contains the RBCs) Upper layer: Platelet-poor plasma. Middle layer: Buffy coat containing PRP. Lower layer: Containing RBCs. Then, buffy coat layers were carefully separated without disturbing the pallet that contained RBCs, which contained platelets (about 1-2 ml). Under all aseptic precautions, the patient was taken to the OT. A lithotomy position was given and anasthesia (TIVA) was given. Under ultrasound sonography (USG) guidence, with the help of an ovum aspiration needle, PRP instillation was performed in the right ovary, and the same procedure was repeated on the left ovary. Haemostasis was achieved, and the patient was moved to the recovery room. After the intraovarian PRP instillation, the AFC level increased to 12. After one month, another OPU was performed with high dose of FSH was given and after 36 hours of triggering, 5 MII and 2 MI oocytes were retrieved. A total of two day 5, one day 5, and two day 3 embryos were formed, and one day 5 and two day 3 embryos were frozen. The first fresh ET was performed with 2 day 5 embryo, but the β-hCG came negative. The first FET was performed after 10 months with 2 day 3 embryo. After 14 days, her blood sample was taken for examination, and β-hcg came 25 mIU/ml (positive). After the ET, the patient was asked to take proper rest and medicines. Her blood sample was taken for examination and β-hCG came back positive. The patient was advised to come to the clinic on a regular appointment.

The inability to achieve pregnancy even after 365 days of regular and unprotected sexual intercourse is known as infertility. The global infertility rate among reproductive couples is estimated to range between 12.6% to 17.5%. A global estimate shows that infertility is among 48.5 to 72.4 million couples.[ 1 ] The infertility in females starts around 25-30 years of age. Approximately 1 out of 8 women aged between 15 to 49 undergo infertility treatment. The main causes of infertility in females are premature ovarian insufficiency, polycystic ovary syndrome (PCOS), endometriosis, uterine fibroid, endometrial polyps, and poor ovarian responder (POR). The AFC (antral follicle count), AMH (anti-Mullerian hormone), and the quality of the eggs declines with age. AMH, AFC, and the no. of eggs obtained are the main causes of POR. It can be treated by PRP injection, coenzyme Q10, and acupuncture and moxibustion.[ 2 ] About 20% of females of fertile age are suffering from PCOS which is a hormonal and metabolic disorder. In PCOS, most of the symptoms start to arise during puberty. PCOS can cause many problems including infertility, insulin resistance, obesity, psychological disorders, and cancer. Hyperandrogenism causes insulin resistance and oxidative stress. PCOS can also caused by genetic and environmental factors such as physical inactivity and poor diet. PCOS causes low ovarian reserve and poor quality of the eggs which leads to low AFC and high AMH level.[ 3 ] There are several studies that demonstrate the effectiveness of PRP in increasing the endometrium thickness and enhancing the implantation rate.[ 4 ] The POR and egg quality is improved by using intra-ovarian PRP. The AFC and AMH level also improves. The research proved that intra-ovarian PRP injection improves the ovarian reserve and quality of oocytes and enhances the levels of AMH.[ 5 ] PRP is injected intra-ovarian along with numerous growth factors (GFs) like transforming growth factor-β (TGF-β), fibroblast growth factor (FGF), epidermal growth factor (EGF), and insulin-like growth factor-1 (IGF-1) and cytokines that are stored in the platelet which acts on the ovary.[ 6 7 ] Inositols such as myo-inositol (MI) and D-chiroinositol (DCI) are a group of nine stereoisomers that play a vital role in balancing glucose metabolism and hormones, especially in conditions like PCOS. MI and DCI help in the regulation of normal secretion of hormone and ovarian function. Some studies concluded that ovarian function and fertility can be enhanced by MI. MI also help to mollified the severity of hyperandrogenism, acne and hirsutism.[ 8 ]

This case study demonstrates the effectiveness of intra-ovarian PRP instillation in a patient suffering from primary infertility due to PCOS, thereby resulting in a successful clinical pregnancy with the help of an ICSI procedure. The successful pregnancy outcome results in the effectiveness of the intra-ovarian PRP. There are no conflicts of interest.

In this study, the patient had a complex scenario of primary infertility with PCOS condition, which indicates low ovarian reserve. So, the patient was given an intra-ovarian injection to see whether it impacted them. According to the research conducted by Parikh et al .[ 9 ] They have evaluated the effect of intra-ovarian PRP instillation in 45 young women with diminished ovarian reserve. The result of the study was that intra-ovarian PRP instillation improves the AFC and AMH levels and the number of total oocytes after two cycles of intra-ovarian PRP instillation. A higher number of clinical pregnancies was observed in women with intra-ovarian PRP instillation than in women without PRP instillation. It has been reported in some literature that PRP had numerous GFs like VEGF (vascular endothelial growth factor) and bFGF (basic FGF) that play a vital role in regulating vascular activation by either activating the latent oocytes and increasing the number of the oocytes. We conducted the study on one woman at the age of 34 years who was suffering from PCOS, which resulted in low ovarian reserve. After the two failed IUI and One IVF, the patient was advised to undergo intra-ovarian PRP instillation. After intra-ovarian PRP instillation in both ovaries, the AFC level improves. During the OPU, seven oocytes were retrieved (five MII and two MI). After one fresh ET and one FET, finally, the patient beta-hcg came positive. According to the research conducted by Rajeev Agarwal et al . in 2023, They evaluated around 66 women of different age groups, and after three cycles of intra-ovarian PRP instillation, there was a significant improvement in the AMH and AFC levels. Improved post-treatment AFC was not only limited to younger patients but showed significant AFC improvements in patients more than 35 years of age. In 45 patients out of 66, oocytes were retrieved post-PRP treatment, and 38 patients (58%) developed embryos. The pregnancy rate achieved was 25%. The PRP treatment was well tolerated, and there were no reports of any effect. The study concluded that the presence of multiple GF in PRP such as VEGF, bFGF, and EGF plays a role in enhancing the AFC and AMH with intraovarian PRP injection.[ 10 ] In our case report, We found that the value of AFC and quality of oocytes increased after the intra-ovarian PRP instillation in the patient who was suffering from PCOS, which led to low ovarian reserve. The intra-ovarian PRP improves the ovarian reserve and function which results in positive clinical pregnancy outcomes in the patient.