Incipient ovarian failure and premature ovarian failure show the same immunological profile

ROS-CCL5 axis recruits CD8+ T lymphocytes promoting the apoptosis of granulosa cells in diminished ovary reserve

Follicular atresia was initiated with the apoptosis of granulosa cells (GCs) mostly mediated by oxidative stress (OS). Our previous studies found that the number of CD8⁺ T cells and proportion of CD8⁺/CD4⁺ T cells increased in the follicles of diminished ovary reserve (DOR). However, the mechanism was still poorly explored. Herein, our results showed that the level of H₂O₂ in follicular fluid (FF) and reactive oxygen species (ROS) in GCs were increased, while the expression of SOD1, SOD2 and GPX1 was down-regulated in GCs with DOR. In addition, we found that OS within a certain range promoted the expression of CCL5 in GCs, which facilitated the infiltration of CD8⁺ T cells to the follicles. In vitro co-culture experiment showed that CD8⁺ T cells inhibited GCs proliferation and promoted their apoptosis through intrinsic apoptosis pathway. Maraviroc, the CCR5 antagonist, alleviated CCL5-induced immune attack of CD8⁺ T cells. Our results indicated that ROS-CCL5 axis recruited CD8⁺ T cells into FF resulting in the apoptosis of GCs in DOR. This has further implications for the understanding of the pathology of DOR and searching for the therapeutic management of this disease.

A review of autoimmunity and immune profiles in patients with primary ovarian insufficiency

Primary ovarian insufficiency (POI) is a complicated clinical syndrome characterized by progressive deterioration of ovarian function. Autoimmunity is one of the main pathogenic factors affecting approximately 10% to 55% of POI cases. This review mainly focuses on the role of autoimmunity in the pathophysiology of POI and the potential therapies for autoimmunity-related POI. This review concluded that various markers of ovarian reserve, principally anti-Müllerian hormone, could be negatively affected by autoimmune diseases. The presence of lymphocytic oophoritis, anti-ovarian autoantibodies, and concurrent autoimmune diseases, are the main characteristics of autoimmune POI. T lymphocytes play the most important role in the immune pathogenesis of POI, followed by disorders of other immune cells and the imbalance between pro-inflammatory and anti-inflammatory cytokines. A comprehensive understanding of immune characteristics of patients with autoimmune POI and the underlying mechanisms is essential for novel approaches of treatment and intervention for autoimmune POI.

Altered T lymphocyte subtypes and cytokine profiles in follicular fluid associated with diminished ovary reserve

PROBLEM

Diminished ovarian reserve (DOR) is a daunting obstacle in in vitro fertilization (IVF) or intra cytoplasmic sperm injection (ICSI), leading to poor reproductive outcomes. We aim to characterize the T cell and cytokine profiles in follicular fluid (FF) and elucidate its contribution to the development of DOR.

METHOD OF STUDY

A total of 92 infertile women were enrolled in the study. We assessed the ultrastructure, proliferation, and apoptosis of granulosa cells (GCs). The levels of CCL5 and cytokines in FF was measured. Additionally, we classified the T cells and analyzed cytokines production in T cell. We further verified whether CCL5 can recruit specific T cell subcytes to the follicles.

RESULTS

Cytoplasmic vacuolization, nucleolar dissociation, partial shortening, swelling, and fusion of mitochondrial cristae were obvious in GCs with DOR. The proliferation of GCs decreased and the proportion of apoptosis increased in DOR. The down-regulation of Bcl-2 and up-regulation of caspase3 were seen in GCs with DOR. The number of CD8⁺ T cells and proportion of CD8⁺ /CD4⁺ T cells in DOR exceeded the control. Higher positive percentage of CD69, CCR5, and IFN-γ in CD8⁺ T cells, lower positive percentage of IL-10 in CD4⁺ T cells and PD-1 in CD8⁺ T cells were detected in DOR. CCL5 accumulated promoting the recruitment of CD8⁺ T cells to the follicles on interaction with CCR5.

CONCLUSION

The abnormal proportion of CD8⁺ T cells and elevated CCL5 and IFN-γ may change the immune balance in FF and impair the growth of GCs, which in turn fuel the progression of DOR.

Research Progress on the Treatment of Premature Ovarian Failure Using Mesenchymal Stem Cells: A Literature Review

Premature ovarian failure (POF) has become one of the main causes of infertility in women of childbearing age and the incidence of POF is increasing year by year, seriously affecting the physical and mental health of patients and increasing the economic burden on families and society as a whole. The etiology and pathogenesis of POF are complex and not very clear at present. Currently, hormone replacement therapy is mainly used to improve the symptoms of low estrogen, but cannot fundamentally solve the fertility problem. In recent years, stem cell (SC) transplantation has become one of the research hotspots in the treatment of POF. The results from animal experiments bring hope for the recovery of ovarian function and fertility in patients with POF. In this article, we searched the published literature between 2000 and 2020 from the PubMed database (https://pubmed.ncbi.nlm.nih.gov), and summarized the preclinical research data and possible therapeutic mechanism of mesenchymal stem cells (MSCs) in the treatment of POF. Our aim is to provide useful information for understanding POF and reference for follow-up research and treatment of POF.

Transplantation of human umbilical cord mesenchymal stem cells to treat premature ovarian failure

As one of the problems and diseases for women before 40 years, premature ovarian failure (POF) could be characterized by amenorrhea, low estrogen levels, infertility, high gonadotropin levels, and lack of mature follicles. Causes of the disease involve some genetic disorders, autoimmunity diseases, and environmental factors. Various approaches have been employed to treat POF, however with limited success. Today, stem cells are used to treat POF, since they have the potential to self-repair and regenerate, and are effective in treating ovarian failure and infertility. As mesenchymal stem cell (MSC) could simultaneously activate several mechanisms, many researchers consider MSC transplantation to be the best and most effective approach in cell therapy. A good source for mesenchymal stem cells is human umbilical cord (HUCMSC). Animal models with cyclophosphamide are required for stem cell treatment and performance of HUCMSC transplantation. Stem cell therapy could indicate the levels of ovarian markers and follicle-stimulating hormone receptor. It also increases ovarian weight, plasma E2 levels, and the amount of standard follicles. Herein, the causes of POF, effective treatment strategies, and the effect of HUCMSC transplantation for the treatment of premature ovarian failure are reviewed. Many studies have been conducted in this field, and the results have shown that stem cell treatment is an effective approach to treat infertility.

Therapeutic Potential of HUMSCs in Female Reproductive Aging

With the development of regenerative medicine, stem cells are being considered more frequently for the treatment of reproductive aging. Human umbilical cord mesenchymal stem cells have been reported to improve the reserve function of aging ovaries through their homing and paracrine effects. In this process, paracrine factors secreted by stem cells play an important role in ovarian recovery. Although the transplantation of human umbilical cord mesenchymal stem cells to improve ovarian function has been studied with great success in animal models of reproductive aging, their application in clinical research and therapy is still relatively rare. Therefore, this paper reviews the role of human umbilical cord mesenchymal stem cells in the treatment of reproductive aging and their related mechanisms, and it does so in order to provide a theoretical basis for further research and clinical treatment.

Effectiveness of Cotreatment with Kuntai Capsule and Climen for Premature Ovarian Failure: A Meta-Analysis

OBJECTIVE

To compare the treatment efficacy of Kuntai capsule with Climen only in the therapy of premature ovarian failure.

METHODS

Randomized controlled trials were electronically retrieved from PubMed, Cochrane Library, Web of science, CBM, CNKI, Wanfang, and Weipu database. In addition, some related papers were manually checked. All papers were assessed according to the Cochrane Handbook for Systematic Reviews of Interventions, and the effective data were analyzed by Revman 5.3 Software.

RESULTS

11 randomized control trials involving 1068 patients were included. Results of meta-analysis showed that E2 (estrogen), the total therapeutic effective rate of the group of Kuntai capsule, and hormone were higher than hormone only. The LH (luteinizing hormone), FSH (follicle-stimulating hormone), and Kupperman score of the group of Kuntai capsule and Climen were lower than Climen only.

CONCLUSION

Available evidence shows that Kuntai capsule with Climen is more effective than Climen in the therapy of premature ovarian failure. Nowadays, the quality of the research studies is low. More large-scaled randomized trials will need to be carried out.

The effects of human umbilical cord-derived mesenchymal stem cell transplantation on endometrial receptivity are associated with Th1/Th2 balance change and uNK cell expression of uterine in autoimmune premature ovarian failure mice

Background

To explore the mechanism of human umbilical cord-derived mesenchymal stem cell (hUMSC) transplantation to improve ovarian function and the endometrial receptivity in autoimmune premature ovarian failure (POF) mice.

Methods

The POF model was established in mice treated with zona pellucida 3 polypeptide fragment (zona pellucida 3, ZP3). The hUMSCs were transplanted into the POF mice through tail vein injection. Following the transplantation, the serum hormone levels of follicle stimulating hormone (FSH), estrogen (E₂), progesterone (P), γ-interferon (IFN-γ), interleukin-2 (IL-2), and interleukin-4 (IL-4) were evaluated by ELISA analysis. Morphological changes of ovarian and uterus tissues were examined by HE staining and immunohistochemistry. The expression of Th1/Th2 cytokines of T cells in spleen and CD56⁺CD16⁻ cells (uterine natural killer cells, uNK cells) in uterine was measured by flow cytometry (FCM) and immunohistochemistry. The expression of HOXA10 in uterine endometrium was examined by immunohistochemistry and RT-PCR analysis. The pinopodes of epithelial cells in uterine endometrium were examined by scanning electron microscopy.

Results

Following hUMSC transplantation, the serum levels of E₂, P, and IL-4 were increased but FSH, IFN-γ, and IL-2 levels were decreased in POF mice. Also, the transplantation of hUMSCs caused an increase in total number of healthy follicles and decrease of atresia follicles. The expression of HOXA10 gene was significantly increased but the CD56⁺CD16⁻ uNK cells decreased in the endometrium of uterine. The ratio of Th1/Th2 cytokines was also significantly decreased.

Conclusion

The data suggest that the recovery of ovarian function and endometrial receptivity in POF mice was regulated by the balance of Th1/Th2 cytokines and expression of uNK cells in the endometrium following hUMSC transplantation.

Dynamics of the ovarian reserve and impact of genetic and epidemiological factors on age of menopause

The narrow standard age range of menopause, ∼50 yr, belies the complex balance of forces that govern the underlying formation and progressive loss of ovarian follicles (the "ovarian reserve" whose size determines the age of menopause). We show here the first quantitative graph of follicle numbers, distinguished from oocyte counts, across the reproductive lifespan, and review the current state of information about genetic and epidemiological risk factors in relation to possible preservation of reproductive capacity. In addition to structural X-chromosome changes, several genes involved in the process of follicle formation and/or maintenance are implicated in Mendelian inherited primary ovarian insufficiency (POI), with menopause before age 40. Furthermore, variants in a largely distinct cohort of reported genes-notably involved in pathways relevant to atresia, including DNA repair and cell death-have shown smaller but additive effects on the variation in timing of menopause in the normal range, early menopause (age <45), and POI. Epidemiological factors show effect sizes comparable to those of genetic factors, with smoking accounting for about 5% of the risk of early menopause, equivalent to the summed effect of the top 17 genetic variants. The identified genetic and epidemiological factors underline the importance of early detection of reproductive problems to enhance possible interventions.

Does autoimmunity play a role in the pathophysiology of premature ovarian ageing?

To determine a possible causative association between autoimmunity and premature ovarian ageing (POA), 394 women undergoing IVF at an academically affiliated private IVF centre were retrospectively evaluated for the presence of autoimmune-related diseases. Out of 162 POA women, 13 (8.0%) demonstrated a history of autoimmune disease(s), while autoimmunity was present in 28 (12.1%) of 232 controls. POA women with poor response (four oocytes or fewer) despite high-dose treatment presented autoimmunity in 7.9%, compared with 12.1% control subjects without autoimmune diseases. When family history was considered (patient and/or first-degree relatives), at least one autoimmune disease was reported in 14 (8.6%) POA and 31 (13.4%) controls with comparable distributions of autoimmune diseases among both groups. Infertile women with premature ovarian ageing and age-appropriate ovarian function show high but comparable prevalences of autoimmune-related diseases. These findings support the assumption that aetiologies other than autoimmune disease lead to POA.

Premature ovarian failure and pregnancy

SETTING

A case study of a woman with presumed premature menopause is presented.

RESULTS

After more than 4 years of premature menopause judged by subjective symptoms, bleeding history, and postmenopausal levels of gonadotropins, a woman conceived spontaneously 2 months after the start of hormone replacement treatment (HRT). Previously, ovarian stimulation with clomifen citrate had failed. She delivered prematurely due to preeclampsia and intrauterine growth retardation.

CONCLUSIONS

Reviewing the literature finds that pregnancy is reported in woman with premature ovarian failure after the use of birth-control pills, HRT, ovarian stimulation, and in spontaneous cycles. Lack of oocyte donors and prohibition of the donor technique in some countries make other options valuable when optimal infertility treatment cannot be offered.

Selective theca cell dysfunction in autoimmune oophoritis results in multifollicular development, decreased estradiol, and elevated inhibin B levels

We describe the clinical course of three women with presumptive autoimmune oophoritis who developed multiple follicles but very low to undetectable estradiol levels. Multiple follicles developed spontaneously in all subjects and during pulsatile GnRH treatment for ovulation induction in subject 1. The development of multiple dominant follicles was accompanied by LH levels in the postmenopausal range and FSH levels at the upper limit for premenopausal women. Serum inhibin B levels were elevated appropriately in the setting of multifollicular development, but estradiol levels remained low. Measurement of estradiol precursors demonstrated androstenedione and estrone levels below the 95th percentile in normal women. Adrenal cortical antibodies, and antibodies to 21-hydroxylase and P450 side chain cleavage enzymes were identified in all subjects. All subjects met the criteria for premature ovarian failure during follow-up. Subject 1 later developed adrenal failure, whereas subject 3 had adrenal failure at the time of the study. These subjects elucidate the hormonal pattern in autoimmune oophoritis, before the full criteria for premature ovarian failure are met. The elevated inhibin A and B levels, which accompany the development of multiple small and dominant follicles in these women, suppress FSH relative to LH levels, virtually independent of estradiol. These data provide further evidence for an important role of inhibin B and inhibin A in the negative feedback control of FSH. In addition, the normal inhibin A and inhibin B production in the absence of estradiol precursors and estradiol provide insight into the selective dysfunction of the theca cells in autoimmune oophoritis.

Body mass index but not a polymorphism of the interleukin-1 receptor antagonist (IL-1 RA) gene is associated with age at natural menopause

BACKGROUND

A genetic component of the onset of menopause has been described and several candidate genes have been identified. We hypothesized that carriage of a polymorphism of the interleukin-1 receptor antagonist gene (IL-1 RA) is associated with an early age at menopause.

METHODS

In a prospective cohort study, 90 consecutive postmenopausal Caucasian women were genotyped by PCR for the presence of an 86-base pair tandem repeat polymorphism in intron 2 of IL-1 RA.

RESULTS

We found that 36/90 (40%) women were homozygous for the wild-type allele 1 and 49/90 (54%) women were heterozygous for any of the variant alleles (1/2 [n = 44], 1/3 [n = 3], 2/3 [n = 2]). Two women (2%) were homozygous carriers of the variant allele 2. The wild-type allele 1 was identified on 119 of 180 chromosomes for an allele frequency of 0.66. The polymorphic alleles 2 and 3 were present on 56 and 5 chromosomes, respectively (allele frequencies 0.31 and 0.03, respectively). No correlation between the IL-1 RA genotype and the age at menarche and menopause, the length of the reproductive period, and the number of deliveries and miscarriages was ascertained. As to allele frequencies, homozygous and heterozygous carriers of the variant allele 2 had a median age at menopause of 50 (range 40-48) years, compared to 49.5 (range 39-56) years for women with no allele 2 (p value 0.41). Women with at least one allele 2 had a median age at menarche of 13 (range 10-16) years, compared to 13 (range 10-17) years for women with no allele 2 (p value 0.1). Decreasing body mass index, but not smoking, was correlated with an increasing age at natural menopause (r = -0.23, p = 0.04).

CONCLUSIONS

Our preliminary data suggest that an 86-base pair tandem repeat polymorphism in intron 2 of IL-1 RA does not modulate the onset and cessation of menses in this cohort of Caucasian women.

Prediction of ovarian reserve based on day-3 serum follicle stimulating hormone concentrations during the pituitary suppression cycle using a gonadotropin releasing hormone agonist in patients undergoing in vitro fertilization-embryo transfer

Satisfactory results following in vitro fertilization-embryo transfer (IVF-ET) treatments depend on retrieving an appropriate number of mature oocytes without causing the development of ovarian hyperstimulation syndrome (OHSS). The present study was carried out to investigate whether the ovarian reserve is predictable based on the day-3 serum concentration of follicle stimulating hormone (FSH) during the pituitary suppression cycle using a gonadotropin releasing hormone (GnRH) agonist (defined as day-3 FSH) in patients undergoing IVF-ET treatment. Day-3 FSH before the administration of gonadotropin was assessed in 72 IVF-ET cycles from 59 infertile women. The mean+/-SD of day-3 FSH, the total amount of FSH plus human menopausal gonadotropin (hMG) administered, and the total number of oocytes retrieved was 5.5+/-2.6 mIU/ml, 2834.2+/-1236.5 IU and 7.7+/-5.8, respectively. There were significant correlations between day-3 FSH and the total amount of FSH-hMG administered (p < 0.001), and day-3 FSH and total number of oocytes retrieved (p < 0.001). There was a significant difference of day-3 FSH between patients who subsequently conceived (4.4+/-1.3 mIU/ml) and those who did not conceive (6.1+/-2.9 mIU/ml) (p = 0.001). There was also a significant difference of day-3 FSH between patients who developed moderate or severe OHSS (4.5+/-1.2 mIU/ml) and those who did not (5.9+/-2.8 mIU/ml) (p = 0.003). Receiver-operator characteristic curve analysis showed that the significant cut-off point for day-3 FSH for predicting ovarian reserve was 5.25 mIU/ml. These findings indicate that day 3-FSH is usefulfor predicting ovarian reserve during the pituitary suppression cycle using a GnRH agonist in patients undergoing IVF-ET.

Ovarian autoimmune disease and ovarian autoantibodies

Detection of specific autoantibodies remains the most practical clinical and research marker of autoimmune disease. The lack of consensus on ovary specific antibodies as a marker for ovarian autoimmunity has clinical and research consequences. The objective of this review is to summarize the evidence for ovarian autoimmunity and the detection of ovary specific autoantibodies in humans. Evidence favors the presence of an autoimmune disease of the ovary. Ovarian autoantibodies are associated primarily with premature ovarian failure (POF) and unexplained infertility. Variations in detection of ovarian autoantibodies are likely to be due to study design elements such as antibody test format, antigen preparation, and criteria for study and comparison groups. In addition, multiple targets appear to be involved in ovarian autoimmunity including ovarian cellular elements and oocyte related antigens. Many studies only assess one target antigen, leaving individuals with ovarian autoimmunity unidentified. The next most significant advance in characterizing ovarian autoimmunity will be definitive identification of the specific antigens and development of standardized tests based on use of specific antigens.