PRP in obst and gynae
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platelet rich plasma obstetrics gynecology
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PMID: 38682756
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PMID: 38214306
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PMID: 38280991
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PMID: 38627790
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PMID: 38493418
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PMID: 41168677
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platelet rich plasma thin endometrium IVF
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Platelet-Rich Plasma (PRP) in Obstetrics and Gynecology
What is PRP?
PRP is an autologous blood product obtained by centrifuging peripheral venous blood, yielding a platelet concentrate (typically 3-5x baseline platelet count) suspended in plasma. The alpha-granules of these concentrated platelets release a cocktail of growth factors upon activation:
| Growth Factor | Role |
|---|---|
| PDGF (Platelet-Derived Growth Factor) | Cell proliferation, angiogenesis |
| VEGF (Vascular Endothelial Growth Factor) | Neovascularization |
| TGF-beta (Transforming GF) | Tissue remodeling, anti-inflammatory |
| EGF (Epidermal GF) | Epithelial regeneration |
| IGF-1 (Insulin-like GF) | Cell survival, differentiation |
| bFGF (Basic Fibroblast GF) | Stromal proliferation |
Preparation: Venipuncture -> single or double-spin centrifugation -> separation of PRP layer -> optional activation with calcium chloride or thrombin before use.
Applications in Gynecology
1. Recurrent Implantation Failure (RIF) - Intrauterine PRP
This is the most studied and evidence-supported indication.
- Indication: Women who have failed ≥2-3 IVF/ICSI embryo transfers despite good-quality embryos
- Mechanism: PRP infusion into the uterine cavity enhances endometrial receptivity by promoting stromal proliferation and pinopode formation; upregulates integrins and adhesion molecules critical for implantation
- Procedure: 0.5-1 mL of activated PRP instilled into the uterine cavity 48-72 hours before embryo transfer via a fine catheter
Evidence: A 2024 network meta-analysis of 56 studies (Xie et al., PMID 38627790) compared 11 intrauterine infusion strategies. PRP ranked highest among all modalities (HCG, G-CSF, PBMC, etc.) for improving clinical pregnancy and live birth rates. In the Cochrane review (Vaidakis et al., PMID 38682756, 12 RCTs, 1069 women), the pooled OR for live birth/ongoing pregnancy favored PRP (OR 2.38, 95% CI 1.16-4.86), though certainty was very low due to high risk of bias in most trials. The one low-risk-of-bias RCT showed no significant effect (OR 1.10, 95% CI 0.38-3.14).
Bottom line: PRP may improve outcomes in RIF, but current evidence is very-low certainty. It is not yet recommended as standard of care; larger, well-designed RCTs are needed.
2. Thin Endometrium
- Definition: Endometrial thickness <7 mm on the day of HCG trigger/FET preparation
- Mechanism: PRP promotes proliferation of endometrial glands and stroma, increases subendometrial blood flow
- Route: Intrauterine infusion (transcervical instillation) or sub-endometrial injection (newer approach)
- A 2025 meta-analysis (Kumar et al., PMID 41286777) compared sub-endometrial injection vs standard intrauterine infusion - sub-endometrial injection may offer superior endometrial thickness improvement, though evidence is preliminary
3. Poor Ovarian Response (POR) / Poor Ovarian Reserve - Intraovarian PRP
- Indication: Women with Bologna criteria for POR (≤3 oocytes with conventional stimulation), low AMH, low AFC; also premature ovarian insufficiency (POI)
- Mechanism: Intraovarian injection delivers GFs directly to the ovarian cortex, potentially activating dormant primordial follicles, improving granulosa cell function, and promoting angiogenesis
- Procedure: Transvaginal ultrasound-guided intraovarian injection of ~1-4 mL PRP, typically 1-3 months before planned IVF cycle
Evidence:
- Wu et al. 2024 meta-analysis (10 trials, 876 patients, PMID 38214306): PRP improved MII oocyte count (MD +1.07), transferable embryo count (MD +0.95), and AFC (MD +1.12). Clinical pregnancy rate 25.4%, live birth rate 16.6%
- Maged et al. 2024 (14 studies, 1632 participants, PMID 38280991): Significant improvements in AFC (MD +1.73, p<0.001) and number of oocytes retrieved (MD +1.21, p=0.001). No significant change in AMH levels
- The Cochrane review found low-certainty evidence for intraovarian PRP vs. no intervention, with clinical pregnancy rates possibly improved
4. Intrauterine Adhesions (Asherman's Syndrome) - Post-Adhesiolysis
- Indication: Prevention of adhesion re-formation after hysteroscopic adhesiolysis
- Mechanism: PRP provides anti-inflammatory GFs that inhibit fibrosis and promote normal endometrial regeneration
- Best approach: PRP + intrauterine balloon (combination)
Evidence: Tang et al. 2024 network meta-analysis (21 RCTs, 2406 patients, PMID 38493418): PRP + balloon was the top-ranked combination for reducing American Fertility Society (AFS) adhesion scores (MD = 5.44, 95% CI 2.63-8.25). The study concluded PRP + balloon is likely the most effective strategy for preventing adhesion recurrence.
5. Vulvovaginal Disorders
De Ponte et al. 2026 systematic review (18 studies, 480 patients, PMID 41168677) identified three main indications for vulvovaginal PRP injection:
| Condition | n | Outcome |
|---|---|---|
| Vulvar lichen sclerosus (VLS) | 179 | Symptom improvement (pruritus, dyspareunia), reduced lichenification |
| Sexual dysfunction (FSD, HSDD) | 133 | Improved arousal, lubrication, orgasm scores - "O-Shot" |
| Vulvovaginal atrophy (GSM) | 87 | Improved vaginal health index, pH, sexual function |
- Protocol: 3-4 sessions of intradermal/submucosal PRP injection, 4-6 weeks apart
- Adverse events: Mild (local pain, transient swelling) - overall favorable safety profile
- All indications showed benefit, but high protocol variability and small samples limit definitive conclusions
6. Other Gynecological Applications
| Application | Status |
|---|---|
| Ovarian rejuvenation (fertility preservation in POI) | Experimental; case reports and small series |
| Post-cesarean scar repair | PRP + hysteroscopy for niche/isthmocele - small studies |
| Endometriosis | Anti-inflammatory properties; preclinical data only |
| Pelvic floor repair | Adjunct to mesh/plication procedures; limited data |
PRP Preparation - Key Points
- Anticoagulant: ACD-A (acid citrate dextrose) preferred; avoids immediate platelet activation
- Single spin (~200g, 10 min): yields leukocyte-poor PRP
- Double spin (~200g then ~400g): higher platelet concentration, may contain leukocytes (L-PRP)
- Activation: Calcium gluconate or thrombin triggers degranulation before injection
- Platelet count target: 1,000,000/μL (5x baseline) considered optimal; higher is not always better
- Leukocyte-poor vs. leukocyte-rich: In gynecology, leukocyte-poor PRP generally preferred to minimize inflammation
Summary of Evidence Levels
| Indication | Best Evidence | Quality |
|---|---|---|
| RIF - intrauterine PRP | Cochrane SR + network MA | Very low certainty |
| Thin endometrium | Multiple RCTs; SR 2025 | Low-moderate |
| POR/POI - intraovarian | 2 meta-analyses (2024) | Low certainty |
| Asherman's - post-adhesiolysis | NMA (21 RCTs, 2406 pts) | Moderate (for AFS scores) |
| Vulvar lichen sclerosus | SR 2026 (18 studies) | Low |
| Vulvovaginal atrophy / FSD | SR 2026 | Low |
Key References (Recent Systematic Reviews)
- Vaidakis D et al. Cochrane SR - PRP for assisted reproduction (2024) - PMID 38682756
- Wu L et al. PRP in poor ovarian response (2024) - PMID 38214306
- Maged AM et al. Intraovarian PRP in POR/POI (2024) - PMID 38280991
- Xie Q et al. Uterine infusion strategies in RIF (2024) - PMID 38627790
- Tang R et al. Intrauterine interventions post-adhesiolysis (2024) - PMID 38493418
- De Ponte A et al. PRP in vulvovaginal disorders (2026) - PMID 41168677
Overall: PRP shows consistent biological plausibility and promising signals across all major OB/GYN applications. The strongest evidence currently exists for post-adhesiolysis adhesion prevention (PRP + balloon). For RIF, POR, and vulvovaginal conditions, results are encouraging but evidence quality remains low due to small sample sizes, heterogeneous protocols, and high risk of bias. Standardization of PRP preparation and injection protocols is a major unmet need before routine clinical adoption.
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