Case Report: Case report: Effect of intraovarian platelet-rich plasma therapy on latent female genital tuberculosis patient

Particulars related to the patient

This case study is based on a middle-aged South Asian couple who selected Wardha Test Tube Baby Centre, Sawangi (M), India, in January 2021 to fulfil their pregnancy dream, hindered by infertility. A 34-year-old middle-aged South Asian woman suffering from secondary infertility for two years out of three years of married life was enrolled for three in vitro fertilisation (IVF) cycles at WTTBC, Wardha. The couple was vividly counselled about the procedure, and duly informed consent was taken from them. The husband was a lecturer by profession, and the wife was a staff nurse. Both parties have no history of smoking, drinking or any addictions.

Medical, family and psychosocial history of the couple

This study gyrates around a woman who was nulligravida. They had no sexual complications in their three years of marital life. She was suffering from secondary infecundity for two years. Semen analysis of the male partner revealed the total sperm count to be 13 million/mL, which is below the lower reference limit as mentioned in WHO 2021 Guidelines.⁶ The male partner was diagnosed with mild oligospermia. The normal morphology of sperm was reported to be 10%.

The patient was diagnosed with a left ovarian cyst in 2019 and suffered from extrapulmonary tuberculosis, validated by a positive Z.N. Stain report in 2021. Tuberculosis mainly affected her endometrium, causing adhesions along with a milder effect on her ovaries. She also had a history of hypothyroidism for the past year. She was under regular medication of thyroid tablet of 125 μg for the last year. In 2022, between the IVF treatment at WTTBC, Wardha, she also suffered from asymptomatic Covid-19, diagnosed by taking an RT-PCR test, which came to be positive. The couple’s family pedigree was also reported to have hypertension.

The couple also had a history of undergoing IUI (intra-uterine insemination) treatment four times before visiting WTTBC, Wardha. All attempts of IUI failed prior to their IVF treatment at WTTBC, Wardha.

Clinical findings of the patient

AMH (anti-Mullerian hormone) is an essential biomarker to gauge the ovarian reserve present in women.⁷ The usual range of serum AMH to predict a healthy ovarian reserve is 2 to 6.8 ng/mL.⁷ In our case study, the value of the serum AMH of the patient was 0.4, which is indicative of a meagre ovarian reserve. The patient's hormonal profile was found to be TSH (thyroid stimulating hormone) 18.09 mIU/L; FSH (follicle stimulating hormone) 4.99 mIU/mL; estrogen 99.319 pg/mL; and LH (luteinizing hormone) 8.97 IU/mL. Upon the use of thyroid supplement tablet of 125 μg for a year, the TSH value was brought down to 3.69 mIU/L. She also had a history of undergoing a diagnostic procedure, dilation and curettage (D&C), with histopathology of the endometrium two years ago to understand the endometrial pathology.

In the first cycle of IVF Treatment, we tried to do a fresh embryo transfer using the self-oocytes of the patient. Gonadotrophin releasing hormone (GnRH) antagonist protocol was followed for the patient. Post this, we administered 10.000 IU of human chorionic gonadotrophin (HCG) injection subcutaneously to the patient, which is responsible for oocyte maturation. We tried to do transvaginal ovum pick-up 36 hours after the injection application. However, no oocytes were found during the procedure.

The couple was counselled on the following condition, and they were prepared for a second round of IVF treatment. Antral follicular count (AFC) is an effective parameter for analysing ovarian health. The patient reported having 1–2 follicular counts in both ovaries. Lower AFC indicates poor ovarian reserve.⁵ We planned to administer IOPRP on both the ovaries for the second round of treatment. We advised the patient to have coenzyme Q10, dehydroepiandrosterone and melatonin combined tablet once a day, and alfacalcidol 0.5 μg and astaxanthin 8 mg combined pill once a day. From day 2 of the menstrual cycle, we started administering minimal ovarian stimulation protocol using 100 mg of clomiphene citrate till day 6. From day 3, 150–225 units of hMG (human menopausal gonadotrophin) were administered to the patient until one follicle reached 17–18 mm in size. On ovulation day, we performed oocyte retrieval on the patient. We prepared the IOPRP sample by withdrawing 15 mL of venous blood from the patient in a conical tube. At first, we centrifuge the sample for 10 minutes under 1200 rpm (190×g). The blood is segregated into three layers. The supernatant and the buffy coat (which is believed to have concentrated platelets) were pipetted into a different conical tube and centrifuged for 10 mins under 2000 rpm (535×g). 4 mL of supernatant, which is our PRP sample was collected with the plan of instilling 1–1.5 mL of the sample per ovary. The aspiration procedure was undertaken transvaginally using guided ultrasound by administering mild anaesthesia to the patient. After removing the dominant follicle, we instilled IOPRP in the collapsed follicle for around 45 seconds. We used 1–1.5 mL of PRP for both ovaries. AFC was recorded as 1 in the right ovary and 2 in the left. Upon subsequent follow-up, we performed the oocyte aspiration procedure again, and IOPRP was followed for round 2. Upon the final aspiration procedure, we were able to retrieve 5 MII Oocytes from the patient. We planned to do a fresh embryo transfer with two embryos and freeze the rest of the embryos for frozen embryo transfer. We performed a fresh embryo transfer on the patient. β-HCG report performed after two weeks of the transfer resulted in negative. The couple was counselled and prepared for a frozen embryo transfer.

During the subsequent visit to our centre, we analysed the thickness of the endometrium. The usual range of endometrium is above 7 mm for the transfer of embryos.⁸ She was started with oestradiol 2 mg tablet twice daily, vitamin supplements and thyroxine 125 μg as a part of pre-medication.

A globally approved thawing kit was used to thaw the embryo and was stored in a benchtop incubator for around 130 mins for the blastocyst to expand. Once the agenda was achieved, we transferred one embryo of 4AA grade (Figure 1) into the uterus. The patient had no discomfort using the procedure in August 2022.

Figure 1. This shows the embryo that was transferred to the patient.

Follow-up diagnostic evaluation and therapeutic applications

After the successful transfer of the embryo, the patient was discharged with the advice of follow-up. The patient was advised to have ofloxacin and ornidazole combined tablet twice daily, omeprazole 40 mg on an empty stomach daily, vitamin E supplement once a day, arginine tablet once a day, vitamin supplements, oestradiol 2 mg tablet twice a day and progesterone 400 mg once a day. She was also advised to injectables of human chorionic gonadotrophin (HCG), hydroxyprogesterone 500 mg and intralipid injection. After two weeks from the day of embryo transfer, we drew a syringe of blood from the patient and sent it for a β-HCG test at our laboratory centre in ABVRH, Sawangi Wardha. The report came to be positive. The level of β-HCG was reported to be 1050 mIU/mL.