Exosome-Enriched Culture Media to Enhance In Vitro Maturation and Embryo Development in Poor Ovarian Responders Undergoing IVF

This is a prospective, single-center, randomized controlled trial designed to evaluate the efficacy of exosome-enriched culture media in promoting the short-term in vitro maturation (IVM) of immature oocytes retrieved from poor ovarian responder patients undergoing in vitro fertilization (IVF).

Rationale:

Poor ovarian responders represent a significant clinical challenge in assisted reproductive technology (ART), often yielding a low number of mature metaphase II (MII) oocytes after controlled ovarian stimulation. A substantial proportion of oocytes retrieved in these patients remain at the metaphase I (MI) stage and traditionally show limited capacity for maturation, thereby reducing the pool of oocytes available for fertilization.

Emerging preclinical data and our pilot observations suggest that exosomes-extracellular vesicles containing bioactive molecules such as miRNAs, proteins, and growth factors-play a crucial role in follicular development and may facilitate oocyte meiotic progression. Incorporating exosomes into IVF culture media could therefore represent a novel strategy to enhance in vitro maturation of MI oocytes and improve outcomes in this difficult-to-treat population.

Study Design and Methods:

The study will enroll 60 women aged 35 to 42 years, all meeting at least two Bologna criteria for poor ovarian response. Patients will undergo controlled ovarian stimulation with antagonist protocols and oocyte retrieval approximately 36-37 hours after hCG administration. Retrieved oocytes will be classified as MI or MII.

MI oocytes will be randomized on a per-patient basis into two groups:

Control group: MI oocytes cultured in pre-equilibrated Cook IVF media without additional supplementation.

Intervention group: MI oocytes cultured in the same media supplemented with 10 µg/well of GMP-certified exosomes (sourced from Exosmart or an equivalent validated supplier).

Oocytes will be monitored for progression from MI to MII at intervals up to 4 hours. Subsequent ICSI will be performed on matured oocytes, and resulting embryos will be cultured to blastocyst stage following standard laboratory protocols.

Outcomes:

The primary endpoint is the proportion of MI oocytes achieving maturation to MII within 4 hours of culture.

Secondary endpoints include fertilization rates (2PN formation), day 3 and blastocyst morphological grading, implantation rates, and clinical pregnancy rates per embryo transfer.

Statistical Considerations:

Data will be analyzed using chi-square or Fisher's exact tests for categorical variables such as maturation and fertilization rates. Logistic regression may be used to adjust for confounding factors such as patient age, baseline AMH, and gonadotropin dose. A p-value <0.05 will be considered statistically significant.

Ethical Considerations:

All patients will provide written informed consent before participation. The study will be conducted in compliance with the Declaration of Helsinki, local regulations, and Good Clinical Practice (GCP) guidelines. The protocol will be reviewed and approved by the appropriate Institutional Review Board (IRB) prior to initiation.

Potential Impact:

By investigating the role of exosome supplementation in improving the maturation of MI oocytes, this study seeks to expand the pool of usable oocytes in poor responder IVF cycles. This could translate to higher embryo availability, reduced cycle cancellations, and ultimately improved pregnancy outcomes in a patient group historically characterized by low success rates.

Inclusion criteria

Inclusion Criteria:

Women aged 35 to 42 years

Undergoing IVF with an antagonist protocol

Meet at least two Bologna criteria for poor ovarian response

Provide written informed consent -

Exclusion criteria

• Exclusion Criteria:

Severe male factor infertility requiring surgical sperm retrieval

Known untreated hydrosalpinx

Uterine anomalies that impair implantation

Known chromosomal abnormalities

Participation in another investigational study within 3 months