Study Protocol: Evaluating the Effect of Autologous Platelet-Rich Plasma Infusion in the Endometrial Cavity for Enhanced Embryo-Endometrium Synchrony in Patients with Repeated Implantation Failure

ABSTRACT

Background:

Repeated implantation failure (RIF) is a significant challenge in IVF treatment, often related to insufficient endometrial thickness and poor embryo-endometrium synchrony. Platelet-rich plasma (PRP) therapy has shown promise in various medical fields but is under-explored in gynecology. This study aims to evaluate the effectiveness of PRP therapy in improving endometrial thickness and enhancing embryo-endometrium synchrony in women with RIF undergoing IVF.

Objectives:

The primary objective is to assess whether PRP therapy improves pregnancy outcomes, endometrial thickness, and embryo implantation rates in women with repeated implantation failure. Secondary objectives include comparing PRP therapy’s effectiveness to traditional IVF without PRP and establishing a standardized protocol for PRP preparation in clinical practice.

Methodology:

This prospective, randomized, controlled trial involved 100 women with a history of repeated implantation failure and thin endometrium. Participants were randomly assigned to two groups: an intervention group (n = 50) receiving autologous PRP therapy and a control group (n = 50) receiving IVF without PRP. PRP was prepared using a two-step centrifugation process. Endometrial thickness, embryo implantation rates, and pregnancy outcomes were compared between the two groups. Statistical analysis was performed using SPSS or R, with descriptive statistics, Chi-square tests, and t-tests.

Expected Results:

It is anticipated that the PRP therapy group will exhibit improved endometrial thickness, higher embryo implantation rates, and better pregnancy outcomes compared to the control group. Additionally, successful embryo transfers and live birth rates are expected to increase in the PRP-treated group.

Study Implications:

This study could provide valuable insights into the role of PRP therapy in enhancing IVF success rates for women with RIF, potentially offering a novel therapeutic approach in fertility treatments.

INTRODUCTION

The ability to start a clinical pregnancy is what fertility means. Some medical professionals combine the terms infertility and subfertility. However, formal definitions are critical for the effective management of reproductive problems. Infertility affects >186 million persons worldwide; the majority of people live in underdeveloped nations. The most significant negative predictor of fertility is age at conception, but other elements, including lifestyle and environmental variables, are also expected to play an increasingly significant impact.[1] The most stressful period in the life of people who suffer from infertility, during treatment and diagnosis, negatively impacts individual feelings. Self-image, self-respect, and sexuality are closely attached to the capacity of reproduction. The frequency and timing of sexual activity are determined by infertility therapy; the typical intimate event is monitored and managed, and couples frequently feel that the medical staff is symbolically present during their most intimate act.[2] Forced and dictated sexual encounters as part of the treatment and management of the condition, as well as the emotional impact of the diagnosis, are often the causes of problems. Both partners may experience sexual dysfunction, which could cause issues at any point in the sexual response.[3] The embryo and endometrium are the two key elements that affect implantation and pregnancy. Implantation requires a viable embryo and a receptive endometrium. Several procedures are utilized in frozen-thawed embryo transfer (FET) cycles to prepare the endometrium. An ultrasound examination is used to gauge the thickness and endometrial pattern. There is disagreement over the ideal recipient endometrium; however, most doctors favor embryo transfer with an endometrium thickness of more than 7 mm. Despite receiving many treatments, some FET cycles must be abandoned because of insufficient endometrial development. A novel method for treating refractory thin endometrium, PRP intrauterine infusion can induce angiogenesis and proliferation with a variety of growth factors and cytokines. With minimal expense and without the risk of transmitted infection or immune reaction, PRP can be produced quickly from an autologous blood sample.[4] There have been no reported harmful side effects of PRP therapy. Since the woman’s blood is used to create platelet-rich plasma, no adverse reactions are predicted. PRP injections may affect different women differently. PRP is linked to increased synthesis of regenerative enzymes, stromal and mesenchymal cell proliferation, and improved cell migration, according to in vitro studies. The fundamental idea behind using the proliferation agents in PRP is the endometrium’s capacity for regeneration during a regular menstrual cycle, through various surgical procedures (such as curettage), or after delivery. An ultrasound, blood test, and thorough review of the patient’s medical history should be conducted by a fertility clinic to see whether a candidate is a patient for ovarian rejuvenation using PRP. All these techniques are often used in fertility testing. Following PRP administration, the clinic will monitor any hormone level changes in the patient, conduct another ultrasound to confirm that the treatment has the intended impact, and then decide when an IVF cycle should be carried out.[5] Although PRP is frequently utilized in other medical specialties, there currently needs to be more evidence of its therapeutic usefulness in obstetrics and gynecology. Nowadays, the use of autologous (PRP) in reproductive medicine. Autologous PRP studied in patients with an unsuccessful implantation failure, thin endometrial lining, and low ovarian reserve have shown promising results.[3,4,5] After three transfers of 10 or more multiple embryos of high-quality, there has been repeated implantation failure (RIF), characterized as infertility. Almost 10% of failed intracytoplasmic sperm injection treatments result from inadequate endometrial thickness. It has been suggested to use a variety of fertility- Estrogen, vitamin E, pentoxifylline to increase local sildenafil, tamoxifen, endometrial thickness, aspirin, and some drugs to boost endometrial perfusion are improved approaches for treating thin uterine linings. Even though assisted reproduction has a success rate of under 30%, RIF remains a significant factor in its failure.[6] Hence, this study shows the effect of autologous PRP on women with recurrent implantation failure.

Study objectives

• A woman with thin endometrium undergoing the positive effect of PRP treatment.

• Comparison of platelet-rich plasma therapy and without using plasma therapy in a woman with thin endometrium.

• To derive a standardized protocol for the extraction of plasma-rich platelet therapy for commercial utilization in patients.

Hypothesis

Platelet-rich plasma leads to improved endometrial thickness in embryo-endometrium synchrony, improvement in recurrent implantation failure patients, and increased live birth outcomes.

METHODS

Study design: This study will be conducted at Sawangi, Wardha, Maharashtra, for the duration of 6 months.

Study population—Women with thin endometrium and repeated implantation failure enrolled at the IVF center, Sawangi (M), fitting into inclusion and exclusion criteria [Table 1].

Table 1.

Inclusion and exclusion criteria

Inclusion	Exclusion
Women who were aged less than 45 years.	Women who are older than 50 years.
Women whose previous IVF treatments had failed because of a thin endometrium.	Women with thick endometrium.
Women with a history of repeated implantation failure (RIF) undergoing IVF treatment.	Women with a history of uterine abnormalities (e.g., fibroids, polyps, or septum) that may affect endometrial function.

Methodology

In the PRP technique, a first centrifuge is used to separate red blood cells (RBCs), followed by a second centrifuge to concentrate platelets. Initially, whole blood is drawn into a tube containing an anticoagulant, such as acid citrate dextrose (ACD). To isolate RBCs from the rest of the blood volume, the first centrifugation, also known as a soft spin, is performed at 1200 RPM for 10 minutes. After this spin, the blood separates into layers, with RBCs settling at the bottom and platelets and white blood cells (WBCs) present in the upper layer. The supernatant plasma, containing platelets, is carefully transferred to a sterile tube without disturbing the lower layer. A second centrifugation is then performed on the plasma at 2000 RPM for 5 minutes, resulting in the concentration of platelets into a pellet. The RBC pellet and platelet pellet are then separated and suspended in a minimal quantity of plasma, approximately 2 to 4 ml, by gently shaking the tube. It is important to avoid chilling the blood at any point before or during platelet separation to ensure the quality and efficacy of the PRP preparation.

Sample size calculation

$$n=\frac{\left(\alpha 2+\frac{22}{K}\right){(Z1-\frac{\alpha }{2}+Z1-\beta )}^2}{{\Delta }^2}$$

Where,

Mean implantation rate in study group = 0.148

Mean implantation rate in control group = 0.04

σ1 = SD of implantation rate in study group = 0.23

σ2 = SD of implantation rate in control group = 0.13

For detecting mean difference of 0.108 i.e. ∆ = 0.148-0.04 = 0.108

$$n=\frac{(0.23*0.23+0.13*0.13){(1.96+084)}^2}{(0.108*0.108)}$$

= 46.91 = 50 patients required in each of the total subgroups

Analysis

This study assessed the impact of platelet-rich plasma (PRP) therapy on endometrial thickness and embryo-endometrium synchrony in women with repeated implantation failure (RIF) undergoing IVF. A total of 100 patients were divided into two groups: 50 receiving PRP therapy and 50 as controls. Statistical analysis using SPSS or R involved descriptive statistics, Chi-square tests, and t-tests to compare pregnancy outcomes, endometrial thickness, and implantation rates. The aim was to determine if PRP therapy improves pregnancy outcomes compared to the control group.

EXPECTED RESULTS

The expected result of this study is that platelet-rich plasma (PRP) therapy will significantly enhance endometrial thickness in women with thin endometrium, leading to improved embryo-endometrium synchrony. This improvement is anticipated to result in higher implantation rates, reduced recurrent implantation failure, and increased live birth outcomes compared to patients who do not receive PRP therapy.

DISCUSSION

Chang et al.[7] conducted the first study to employ PRP in thin-lining women, who discovered a rise in better pregnancy outcomes and endometrial thickness. Five ladies who had unsuccessful IVF cycles were studied and had poor endometrial responses to standard hormone therapy. All were given 6 mg/day of estradiol for endometrial preparation, potentially increasing to 12 mg/day. The endometrial lining remained 7mm despite all individuals receiving higher dosages of estradiol. These women had intrauterine autologous PRP injection and hysteroscopic lysis of uterine adhesions (if present). Two women had one infusion, and four received two inputs of PRP, depending on the endometrial lining’s measurement, 72 hours after the PRP injection. After receiving PRP infusions, all five women experienced a rise in endometrial thickness, reaching 7mm on the day of progesterone delivery.

According to Nilo Frantz et al.,[1] 80 women with RIF participated in prospective randomized research. Age 41 years and at least two past IVF failures were requirements for admission. Forty-eight hours before E.T., women in the PRP group received 1.5 ml of intrauterine PRP For individuals with less than 7 mm endometrial thickness, an E.T. was performed 48 hours after the initial PRP injection and another 48 hours afterwards. Although not statistically significant, the PRP group’s live birth rates and clinicals were higher. According to Zargar et al., using PRP in women with RIF only considerably improves the outcome. The study findings and interpretation are dubious because 80 women endured frozen and fresh cycles. Instead of combining both, the researchers should have employed only new or only FET processes.[8]

Leila Nazari et al. (2020) states that the study aimed to determine whether autologous platelet-rich plasma (PRP) can enhance the pregnancy rate in cases of repeated implantation failure (RIF). She enrolls 138 patients who have undergone three or more embryo transfers without success and are candidates for frozen-throw embryo transfer after being evaluated for study eligibility. In the case of repeated implantation failure (RIF), intrauterine (PRP) therapy may help enhance pregnancy outcomes.[9]

According to Fady l Zarara Sharara (2021),[3] the research demonstrates that autologous PRP therapy increases endometrium thickness in women with thin endometrium and improves chemical and clinical pregnancy rates. Autologous intraovarian PRP therapy raised anti-Mullerian hormone (AMH) levels. It lowered follicle-stimulating hormone (FSH) in women with poor ovarian reserve, with a tendency to increase clinical and birth rates. Patients who experienced repeated implantation failure (RIF) also showed this trend.

According to Hounyoung Kim et al.[10] (2019), the live birth rate and implantation pregnancy of a patient with a thin endometrial lining can be improved using autologous PRP They assume that autologous PRP capacity that repairs the endometrium receptivity of injured endometrium involves more than rising EMT For further study, they need to reveal the treatment on a molecular based.

Study implications

The study has significant implications for improving outcomes in women with thin endometrium and recurrent implantation failure. By demonstrating the efficacy of platelet-rich plasma (PRP) therapy in enhancing endometrial thickness and synchrony with embryo implantation, this research can revolutionize fertility treatments. The establishment of a standardized PRP preparation protocol ensures consistent results and paves the way for its broader clinical application. This could lead to higher implantation rates, reduced IVF failures, and improved live birth outcomes, offering hope to patients struggling with infertility while contributing to advancements in reproductive medicine.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.