The effect of intratesticular autologous platelet-rich plasma injection on sperm retrieval rates and in vitro fertilization outcomes in couples with non-obstructive azoospermia.

AIM: To assess the efficacy of intratesticular injection of autologous platelet-rich plasma (PRP) in men with non-obstructive azoospermia (NOA) and a history of failed microdissection-testicular sperm extraction (mTESE) procedures. METHODS: A prospective case series of a cohort study was conducted involving couples diagnosed with NOA. Patients with at least one failed mTESE procedure were included. Intratesticular PRP injection was performed using a standardized protocol. Follow-up assessments included sperm analysis, hormonal evaluation, and in vitro fertilization (IVF) outcomes. RESULTS: Data from 177 men with NOA were analyzed, with 135 patients meeting eligibility criteria. PRP treatment resulted in positive sperm retrieval rates of 27.5% in patients with one prior failed mTESE procedure and 16.4% in patients with two or more failed attempts. IVF outcomes showed fertilization rates of 86.4% and 100.0% in respective groups, with pregnancy rates of 36.8% and 22.2% per embryo transfer. Histopathological examination post-mTESE revealed varied patterns, including Sertoli cell-only syndrome and maturation arrest. CONCLUSIONS: Intratesticular PRP injection shows promise as a potential therapeutic approach for NOA patients with prior failed mTESE procedures, demonstrating improved sperm retrieval rates and favorable IVF outcomes. Further randomized controlled trials are warranted to validate these findings and refine the technique's efficacy in male infertility management to answer the question of whether PRP could significantly improve the second attempt retrieval rate.

Might retrigger with human chorionic gonadotropin be a solution for empty follicle syndrome after gonadotropin releasing hormone agonist trigger?

Objective: This study aimed to determine whether the use of human chorionic gonadotropin (hCG) as a trigger could offer a potential solution for addressing empty follicle syndrome following the administration of a trigger for gonadotropin-releasing hormone agonist. Materials and Methods: A retrospective cohort analysis was conducted using data extracted from the hospital database pertaining to 415 patients who underwent in vitro fertilization (IVF) with an antagonist protocol triggered by a gonadotropin-releasing hormone (GnRH) agonist between December 2019 and January 2023 at the Acibadem Maslak Hospital Assisted Reproductive Technologies Unit. All cases that failed to obtain oocytes and required rescue were analyzed. Results: This study analyzed 415 women who underwent IVF using GnRH agonist-triggered antagonist protocols. Among them, 6 (1.4%) had empty folicle syndrome (EFS). Patients with EFS had lower luteinizing hormone levels and fewer oocytes, embryos, and blastocysts, resulting in lower oocyte utilization rate. However, pregnancy rates were similar, with no biochemical or ectopic pregnancies observed in the EFS group. Conclusion: Use of an hCG retrigger in hyperresponders with no oocytes after GnRHa trigger may prevent cycle cancelation. Although the rates of egg utilization may decrease, oocyte maturity remains comparable. Frozen embryo transfer following hCG retrigger administration yields similar positive pregnancy test results and live birth rates.

Does dual trigger improve euploidy rate in normoresponder? A cross-sectional study.

Background: With the introduction of the dual triggering-gonadotropin-releasing hormone (GnRH) analog and recombinant human chorionic gonadotropin (hCG) combination, women with a history of low mature oocyte proportion and empty follicle syndrome were shown to benefit from the dual trigger. Objective: To investigate whether dual triggering of oocyte maturation with a GnRH agonist (GnRHa) combined with hCG can affect the euploidy rate and improve in vitro fertilization outcomes for normoresponder women. Materials and Methods: In this cross-sectional study, 494 women who underwent controlled ovarian stimulation with hCG (n = 274) or dual triggering (hCG+GnRHa, n = 220) at Acibadem Maslak hospital, Assisted Reproductive Unit, from January 2019-2022 were enrolled in this study. Preimplantation genetic testing for aneuploidy was performed on all participants. Results: Both groups had similar baseline and clinical characteristics. Of the 881 embryos biopsied, 312 (35.4%) were reported as euploid in the hCG trigger group; in the dual trigger group, 186 (29.8%) of 623 screening embryos were reported as euploid. The hCG group had a higher euploidy rate per biopsied embryo, although the difference was not statistically significant (31.4 ± 26.5 vs. 26.5 ± 33.3, p > 0.05). Conclusion: In normoresponders, adding GnRHa for final follicular maturation to hCG did not improve the euploidy rate.

What should be the strategy in case of a big follicle at the start of the cycle? Shall we start the stimulation or postpone it to the next cycle?

Objective: This study facilitates decision-making when an antral follicle diameter >15 mm is detected at the beginning of the menstrual cycle in poor responder (POR) patients. Materials and Methods: Eighty-three POR patients with at least one leading follicle with a diameter of 15 to 24 mm on the 2nd-4th days of the menstrual cycle were assessed. Results: The mean age of females was 40.1±4.8 (26-45), and the mean partners' age was 42.1±7.8 (26-65). Fifty-one (61.4%) women underwent an oocyte pick-up procedure 36 h after the first ultrasonographic examination on the 2nd-4th days of the menstrual cycle. Gonadotrophin stimulation was initiated in 32 (38.6%) patients. Among women in whom oocyte retrieval was performed, an oocyte was obtained in 49 (59.75%) patients. In 13 of 49 patients (26.5%), no mature oocytes were obtained. Fertilized 2pn embryos were obtained in 18 of 33 patients (54.5%). Among the fertilized embryos, 12 were good, six were moderate, and two were of poor quality. Following the frozen embryo transfer procedure, one of the two patients experienced a clinical pregnancy. Conclusion: Patients with POR are still difficult to manage both clinically and therapeutically. Since every oocyte is valuable and important, patients should be carefully followed up. Our research will be directed by the need to rule out a physiological ovarian cyst when large antral follicles appear at the beginning of the cycle. The clinician should give them a chance.

Ovarian reserve parameters and IVF outcomes in 510 women with poor ovarian response (POR) treated with intraovarian injection of autologous platelet rich plasma (PRP).

The aim of the current study was to characterize ovarian reserve parameters and IVF outcomes in women with a history of poor ovarian response (POR) treated with intraovarian injection of autologous platelet rich plasma (PRP). Reproductive age women (N=510; age range 30-45yo) diagnosed with POR based on Poseidon criteria were included in the study. PRP treatment resulted in higher AFC, higher serum AMH, lower serum FSH, and a higher number of mature oocytes and cleavage and blastocyst stage embryos. After PRP injection, 22 women (4.3%) conceived spontaneously, 14 (2.7%) were lost to follow up, and 474 (92.9%) attempted IVF. Among women who attempted IVF, 312 (65.8%) generated embryos and underwent embryo transfer, 83 (17.5%) achieved a pregnancy, and 54 (11.4%) achieved sustained implantation/live birth (SI/LB). In total, of the 510 women with POR and mean age of 40.3, PRP resulted in improvement of ovarian reserve parameters, a pregnancy rate of 20.5% and SI/LB rate of 12.9%. Our findings suggest that PRP treatment may be considered in women with POR. For wider clinical application, its clinical efficacy will need to be demonstrated in prospective randomized clinical trials.

Effects of intraovarian injection of autologous platelet rich plasma on ovarian reserve and IVF outcome parameters in women with primary ovarian insufficiency.

We aimed to determine whether intraovarian injection of autologous platelet rich plasma (PRP) improves response to ovarian stimulation and in vitro fertilization (IVF) outcome in women with primary ovarian insufficiency (POI). Women (N=311; age 24-40) diagnosed with POI based on ESHRE criteria underwent intraovarian PRP injection. Markers of ovarian reserve, and IVF outcome parameters were followed. PRP treatment resulted in increased antral follicle count (AFC) and serum antimullerian hormone (AMH), while serum follicle stimulating hormone (FSH) did not change significantly. After PRP injection, 23 women (7.4%) conceived spontaneously, 201 (64.8%) developed antral follicle(s) and attempted IVF, and 87 (27.8%) had no antral follicles and therefore did not receive additional treatment. Among the 201 women who attempted IVF, 82 (26.4% of total) developed embryos; 25 of these women preferred to cryopreserve embryos for transfer at a later stage, while 57 underwent embryo transfer resulting in 13 pregnancies (22.8% per transfer, 4% of total). In total, of the 311 women treated with PRP, 25 (8.0%) achieved livebirth/sustained implantation (spontaneously or after IVF), while another 25 (8.0%) cryopreserved embryos. Our findings suggest that in women with POI, intraovarian injection of autologous PRP might be considered as an alternative experimental treatment option.