Ovarian aging leads to a decline in both the quantity and quality of oocytes, negatively impacting the formation of genetically normal (euploid) embryos during in vitro fertilization (IVF) treatment and increasing the frequency of miscarriage [1]. The aging process leads to cellular and molecular events such as disturbances in mitochondrial dynamics and mRNA storage, translation, and degradation within the oocytes, all of which contribute to meiotic aberrations [1].

Platelet-rich plasma (PRP) is derived from whole blood, which contains plasma (55%), red blood cells (41%) platelets and white blood cells (4%), by centrifugation and separation of its different components [2]. The centrifugation and separation process leads to the removal of red blood cells and the production of plasma with 5–10 times higher concentrations of growth factors. The platelets present in PRP contain alpha granules that, when activated, release many factors that contribute to growth, cell proliferation, and angiogenesis [3]. The growth factors present in PRP have been shown to play an important role in enhancing collagen synthesis, proliferation of bone cells, fibroblast chemotaxis, macrophage activation, angiogenesis, chemotaxis of immune cells, migration and mitosis of endothelial cells, differentiation of epithelial cells, and cytokine secretion by mesenchymal and epithelial cells [2].

Autologous PRP therapy uses injections of the patient's own concentrated platelets and plasma following a venous blood draw. The theory behind using this modality for treatment stemmed from the natural healing process being the body’s initial response to tissue injury by delivering activated platelets and releasing growth factors. The clinical use of PRP has considerably increased over the last decade, and now includes treatments for musculoskeletal injuries [4-6] arthritis [7], periorbital rejuvenation [8], pancreatic problems [9], dentistry [10], wound healing [11], alopecia [12], and infertility [13]. PRP treatment has recently been used as an adjunct in assisted reproduction technology, in particular, as an intraovarian injection in conjunction with IVF for women who have poor ovarian reserve, premature ovarian insufficiency, and even menopause [14-18].

Recent data have shown that intraovarian PRP treatment led to improvement in markers of ovarian reserve such as serum anti-Müllerian hormone (AMH), a marker of ovarian reserve, and increased oocyte yield with IVF [19]. Although recent studies have demonstrated that PRP led to improvements in folliculogenesis and biomarkers of ovarian reserve, the effect of intraovarian PRP administration on embryo genetics has not been studied, except for one case report that demonstrated qualitative improvement in embryo genetics after intraovarian injection of autologous PRP [20]. We report a pilot study of patients who had preimplantation genetic testing for aneuploidy (PGT-A) before and then within 3 months following intraovarian PRP administration.

The mean age of all participants was 40.08±1.46 years, and their mean body mass index was 26.18±1.18 kg/m². When comparing clinical data between cycle 1 and cycle 2, statistically significance differences were not found for serum follicle-stimulating hormone levels (7.98±1.01 mIU/mL vs. 8.45±1.55 mIU/mL, respectively; p=0.66), the antral follicle count calculated by transvaginal ultrasound (11.09±1.82 vs. 12.36±2.36, respectively; p=0.25), the number of oocytes collected (6.18±1.61 vs. 7.27±1.68, respectively; p=0.21), and the number of good-quality embryos formed at the blastocyst stage (3.08±0.88 vs. 2.17±0.49, respectively; p=0.11) (Table 1). Because we used exactly the same protocol for gonadotropins before and after PRP, there was no significant difference in the dose of medications used between cycle 1 and cycle 2 (p>0.05). Among all participants, 3 out of clinical pregnancies were noted among this patient group 1 (8.11%), while 11 out of 28 embryos were euploid in cycle 2 (39.28%, p=0.002). Table 2 shows the individual results for each participant. Three clinical pregnancies were noted among the outcomes of this patient group. The remainder of the patients are either still banking more euploid embryos or in the process of preparing for embryo transfer.

For many older infertile women with low ovarian reserve, the production of an euploid embryo is a major challenge along their journey [23]. Here, we present, to our knowledge, the first case series comparing IVF euploidy rates pre-PRP and post-PRP (within 3 months following the PRP procedure). The autologous PRP is known to contain cytokines, chemokines, and growth factors including platelet-derived growth factor, stromal cell derived factor 1, and hepatocyte growth factor [24]. These molecular signals are known to initiate the recruitment, proliferation, and activation of fibroblasts, neutrophils, monocytes, which are expected to regulate angiogenesis and tissue perfusion which might be an independent way to achieve ooplasm improvement within the adult human ovary [19].

Placing autologous cytokines within ovarian tissue may facilitate the production of higher AMH levels by granulosa cells and improve blastocyst ploidy. One possible mechanism is that any new follicles recruited and good quality oocytes obtained after the intraovarian injection of these growth factors have always resided in the ovaries, but are then stimulated by the PRP administration [25]. Another mechanism could be that the platelet growth factors present in the PRP activate, by supplying molecular signals, the existing ovarian stem cells to differentiate into de novo oocytes [2]. In vitro studies demonstrating the effect of PRP on the growth and survival of isolated early human follicles tend to support such theories, as the development and survival rates of preantral follicles in PRP-supplemented culture media have been found to be significantly higher than in media without PRP supplementation, as demonstrated in a dose-dependent manner with both fresh and vitrified ovarian samples [25]. Finally, the oocytes of older women have aberrant meiotic events and impaired fertilization, resulting in poor embryonic development, partly due to altered mitochondrial number and function [26]. Studies have shown that aneuploid embryos have relatively high mitochondrial DNA copy numbers [27]. It is plausible that PRP improves ooplasm quality by altering the mitochondria, leading to improvements in meiosis and thus resulting in ploidy rescue of the embryos.

The limitations of this case series include a small sample size and the lack of a control group, such a group would have been women who underwent ovarian puncture without the injection of PRP, since mechanical puncture of the ovaries could have an effect on ovarian function. Even though all the patients in this reported a history of prior failed IVF, other limitations include the wide range in the ages of patients (from 28 to 45 years old) and the lack of complete pregnancy outcomes in all participants because many of them are still trying to bank more euploid embryos.

In summary, there is a clear need for well-designed studies pertaining to the effect of the commonly used intraovarian PRP administration in women who struggle to form euploid embryos and who ultimately resort to the use of donor oocytes. Some investigators have explored the ovarian germline stem cell niche and its probable regulatory mechanisms with the hope of yielding valuable insights for the treatment of ovarian aging [28]. Investigations related to the effect of PRP on ovarian stem cells are likely to clarify the signaling pathways involved in de novo oocyte replenishment and follicular development, potentially helping older women with abnormal embryo genetics [29].