Female reproductive decline is determined by remaining ovarian reserve and age

Cathepsin B Regulates Ovarian Reserve Quality and Quantity via Mitophagy by Modulating IGF1R Turnover

The quality and quantity of the ovarian reserve are meticulously regulated through various cell death pathways to guarantee the availability of high-quality oocytes for fertilization. While apoptosis is recognized for contributing to maintaining ovarian reserve, the involvement of other cell death pathways remains unclear. Employing chemical genetics and proteomics, this study reveals the crucial involvement of Cathepsin B in maintaining the ovarian reserve. Results indicate that apoptosis and autophagy play pivotal roles, and inhibiting these pathways significantly increases follicle numbers. Proteomics reveals a dynamic shift from apoptosis to autophagy during follicular development, with Cathepsin B emerging as a key player in this transition. Inhibiting Cathepsin B not only mimics the augmented oocyte reserve observed with autophagy inhibition but also upregulated IGF1R and AKT-mTOR pathways without compromising fertility in pre- and postpubertal mice. Further, IGF1R inhibition partially compromised the protective effects of Cathepsin B inhibition on oocyte reserves, suggesting their interdependence. This association is further supported by the finding that Cathepsin B can degrade IGF1R in vitro. Moreover, the increased IGF1R levels enhance the oocyte mitochondrial membrane potential via transcriptional regulation of mitochondrial biogenesis and mitophagy genes. Remarkably, this Cathepsin B-dependent ovarian reserve maintenance mechanism is conserved in higher-order vertebrates. Cumulatively, our study sheds valuable light on the intricate interplay of autophagy, Cathepsin B, and growth factors in ovarian reserve maintenance, offering potential therapeutic strategies to delay ovarian aging and preserve fertility.

Ovarian tissue cryopreservation for fertility preservation: a two-decade single-center experience with 451 children and adolescents

BACKGROUND

Ovarian tissue cryopreservation (OTC) is the only fertility preservation option for premenarcheal girls before gonadotoxic treatment, but is still considered to be experimental in pediatric patients. This study investigated storage behaviors across different age groups to refine counseling approaches for pediatric patients.

METHODS

This retrospective study analyzed data from children (0-14 years), adolescents (15-19 years), and adults (≥ 20 years) who underwent OTC between 2000-2021 at the University Hospital Bonn's cryobank. Comparison to adults (age ≥ 20 years) was conducted.

RESULTS

Of 2,475 patients, 6% were children and 12% adolescents. Sarcoma was most common in children, lymphoma in adolescents. Adults had longer active storage than children (5.5 vs. 4.7 years, p = 0.011), but for active storage ≥ 10 years, children and adolescents stored longer than adults (13.1 and 12.6 vs. 11.8 years, p ≤ 0.01). The proportion of adolescents increased, while that of children decreased in long-term storage. Median ovarian cortex surface before cryopreservation was 3.5 cm2 in children and 4.5 cm2 in adolescents. Leukemia and sarcoma had the highest mortality rates in children (25% and 13.5%). Overall, pregnancy and birth rates following ovarian tissue transplantation (OTT) were 34.5% and 24.1%, respectively. Among adolescents, pregnancy rates were 33.3% after OTT and 27.3% without OTT, while all children without OTT achieved pregnancy (100%).

CONCLUSIONS

Children and adolescents represent a small subset of OTC patients, with indications linked to common pediatric malignancies. For active storage ≥ 10 years, they store longer than adults, likely due to delayed reproduction or awaiting in vitro growth / in vitro maturation in hematological cases. Overall, adults store longer, but adolescent storage has risen over time possibly due to higher child mortality and previously limited OTC use in younger patients. Mean ovarian cortex surface data may guide pediatric tissue harvest recommendations, with unilateral oophorectomy advised. Fertility preservation counseling and cost coverage should be standard for pediatric patients undergoing gonadotoxic treatment. A tailored approach to OTC indications is essential, especially in high-mortality cancers like leukemia or sarcoma. Favorable pregnancy rates observed, even without OTT, suggest possible OTC overutilization, highlighting the need for individualized strategies and careful clinical decision-making to balance risks and preserve reproductive potential.

Puberty progression in girls with Turner syndrome after ovarian tissue cryopreservation

OBJECTIVE

To study the impact of unilateral ovariectomy for ovarian tissue cryopreservation (OTC) on the function of the remaining ovary in girls with Turner syndrome.

DESIGN

A prospective cohort study as a follow-up of OTC in a research setting (the TurnerFertility trial, NCT03381300).

SUBJECTS

A total of 28 girls with Turner syndrome with follicles in their cryopreserved ovarian cortex tissue, aged 5-19 years. Of the 28 girls, 21 had a 45,X/46,XX mosaic karyotype; 5 had structural aberrations of the X chromosome; 1 had a 45,X monosomy; and 1 had a 45,X/47,XXX karyotype.

INTERVENTIONS

Girls were monitored annually after OTC for pubertal development and levels of antimüllerian hormone (AMH), follicle-stimulating hormone, luteinizing hormone, estradiol, and inhibin B.

MAIN OUTCOME MEASURES

Thelarche, menarche, and onset of premature ovarian insufficiency.

RESULTS

The girls were monitored for a median duration of 3.4 years (maximum 6.6 years). The pubertal development of five prepubertal girls is still unknown; all were aged <10 years and had low gonadotropin and estradiol levels at the end of the follow-up. Seven of the eight girls of approximately pubertal age (10-12 years) experienced spontaneous thelarche, although one received medication to induce puberty. Eleven of the 14 girls between the ages of 14-17 years experienced spontaneous menarche; three other girls with thelarche still had ongoing puberty at the end of follow-up with normal gonadotropins and AMH levels above the detection limit. Approximately 6-12 months after OTC, a decline in AMH concentration was observed in 57% (16/28) of girls, followed by an increase in AMH concentration in the following years. Six of the total 28 girls started hormone replacement therapy because of symptoms of premature ovarian insufficiency, and all had AMH levels <0.50 μg/L before OTC.

CONCLUSION

Pubertal development progressed after unilateral ovariectomy for OTC in most girls with Turner syndrome. Hormone replacement therapy was required within a few years for girls with unfavorable parameters before OTC, such as AMH levels <0.50 μg/L. Decisions regarding OTC should be personalized, considering the girl's preferences and specific characteristics.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03381300.

Unilateral Oophorectomy and Age at Natural Menopause: A Longitudinal Community-Based Cohort Study

OBJECTIVE

To determine the association between unilateral oophorectomy (UO) and age at natural menopause.

DESIGN

Secondary analysis of survey data from Alberta's Tomorrow Project (2000-2022).

SETTING

Prospective cohort study in Alberta, Canada.

POPULATION

23 630 women; 548 experienced UO and 23 082 did not experience UO.

METHODS

Flexible parametric survival analysis was used to analyse age at natural menopause, and logistic regression was used to analyse early menopause and premature ovarian insufficiency by UO status, controlling for birth year, parity, age at menarche, past infertility, hormonal contraceptive use and smoking.

MAIN OUTCOME MEASURES

Age at natural menopause occurred by a final menstrual period without medical cause and sub-classified as early menopause (< 45 years) and premature ovarian insufficiency (< 40 years).

RESULTS

Compared to no UO, any UO was associated with elevated risk of earlier age at natural menopause, which was strongest in early midlife (adjusted HR at age 40 1.71, 95% CI 1.31-2.19) and diminished over time. Compared to age 55 years at UO, risks of earlier age at natural menopause were largest and uniform in magnitude when UO occurred between approximately ages 20-40 years (adjusted HR for UO at age 30 2.32, 1.46-3.54) and then diminished as age at UO approached the average age at natural menopause. Any UO was associated with higher odds of early menopause (adjusted OR 1.90, 1.30-2.79) and premature ovarian insufficiency (adjusted OR 3.75, 1.72-8.16).

CONCLUSIONS

Unilateral oophorectomy is associated with earlier age at natural menopause, particularly when performed before 40 years of age.

Associations between the time interval from myomectomy to subsequent pregnancy and the obstetric outcomes: A population-based cohort study

OBJECTIVE

To investigate the associations between time interval from myomectomy to pregnancy (TIMP) and subsequent pregnancy and obstetric complications, and to explore whether these associations vary according to maternal age at birth.

METHODS

A retrospective population-based cohort study was conducted from 2008 to 2017. Data were extracted from the National Health Insurance Research Database and the Taiwan Maternal and Child Health Database, comprising 2024 379 births from 1 391 856 pregnancies. Eligible cases were identified using diagnostic and procedure codes; 4006 first singleton births in 4006 women after their first laparotomic myomectomy were identified. We estimated the risks of pregnancy and obstetric outcomes according to TIMP (<6, 6-11, and ≥12 months). Subgroup analysis was performed by further dividing according to maternal age at birth (18-34 vs ≥35 years old).

RESULTS

We observed higher risks of gestational hypertensive disorders (adjusted odds ratio [aOR] 1.97, 95% confidence interval [CI] 1.22-3.18, P = 0.005) and neonatal death (aOR 4.59, 95% CI 1.49-14.18, P = 0.008) for TIMP of <6 months versus TIMP of 6-11 months. Likewise, a TIMP ≥12 months was associated with increased risks of gestational hypertensive disorders (aOR 1.72, 95% CI 1.14-2.58, P = 0.010), and neonatal death (aOR 3.27, 95% CI 1.16-9.24, P = 0.025) versus a TIMP of 6-11 months. In subgroup analysis, women over 35 years old still had higher risks of gestational hypertensive disorders when TIMP was <6 months (aOR 2.26, 95% CI 1.17-4.37, P = 0.015) or ≥12 months (aOR 2.04, 95% CI 1.17-3.54, P = 0.012), and a higher risk of neonatal death when TIMP was <6 months (aOR 4.05, 95% CI 1.06-15.53, P = 0.041); whereas women aged 18-34 years old did not.

CONCLUSIONS

This study suggests that a TIMP between 6 and 11 months is associated with lower risks of gestational hypertensive disorders and neonatal death compared with a TIMP <6 months or ≥12 months, especially for women over 35 years old.

The cycling and aging mouse female reproductive tract at single-cell resolution

The female reproductive tract (FRT) undergoes extensive remodeling during reproductive cycling. This recurrent remodeling and how it shapes organ-specific aging remains poorly explored. Using single-cell and spatial transcriptomics, we systematically characterized morphological and gene expression changes occurring in ovary, oviduct, uterus, cervix, and vagina at each phase of the mouse estrous cycle, during decidualization, and into aging. These analyses reveal that fibroblasts play central-and highly organ-specific-roles in FRT remodeling by orchestrating extracellular matrix (ECM) reorganization and inflammation. Our results suggest a model wherein recurrent FRT remodeling over reproductive lifespan drives the gradual, age-related development of fibrosis and chronic inflammation. This hypothesis was directly tested using chemical ablation of cycling, which reduced fibrotic accumulation during aging. Our atlas provides extensive detail into how estrus, pregnancy, and aging shape the organs of the female reproductive tract and reveals the unexpected cost of the recurrent remodeling required for reproduction.

Expert consensus on fertility preservation in hematopoietic stem cell transplantation in girls in China

Aims: Preconditioning before hematopoietic stem cell transplantation (HSCT) seriously damages the ovarian function and causes female infertility. This consensus focuses on the fertility preservation(FP) for girls needing HSCT, aim to make doctors in different disciplines aware of the importance, necessity and technique of ovarian protection.Materials and methods: Summarizing relevant literature and organizing multidisciplinary experts, including obstetrics and gynecology, reproductive medicine, oncology, pediatrics and hematology for full discussion.Results: Individuals exposed to HSCT in childhood are at higher risk of loss of fertility. Considering the high risk of premature ovarian insufficiency (POI) after conditioning and negative impact of POI on fertility, physical and mental health, it is absolutely necessary to protect fertility before HSCT conditioning. Ovarian tissue cryopreservation is the main fertility preservation option for these population.Conclusions: Fertility preservation before HSCT conditioning is crucial. Ovarian tissue cryopreservation is often the only option for these population.

The Relationship Between Serum Anti-Müllerian Hormone and Basal Antral Follicle Count in Infertile Women Under 35 Years: An Assessment of Ovarian Reserve

Introduction Estimating ovarian reserve has been the cornerstone of designing treatment plans for female infertility over the last few years. The most reliable biomarker for assessing female fertility is the antral follicle count (AFC). Also, the anti-müllerian hormone (AMH) is a sensitive test for predicting ovarian reserve and is precisely associated with AFC value. Objective The study aimed to investigate the relationship between serum AFC and AMH levels. Methods This cross-sectional type of observational study included 101 healthy infertile women aged 20-35 years and with low serum AMH. The mean difference in basal AFC among different age groups was evaluated using an independent sample t-test, revealing no significant difference. A multiple regression model was used to assess the association between serum AMH, and other factors related to demographics and other aspects of infertile women with basal AFC. Results The mean age of infertile women in our study was 30.7±3.69, and 29.7% of females had secondary infertility. The highest ovarian reserve was notable among the group 20-25 years, and the lowest follicular volume was observed in the 31 to below 35 years. Multiple regression analyses revealed that serum AFC and AMH had a strong positive association with basal ovarian volume. Additionally, every one-unit surge in AFC and AMH was statistically significant (p<0.05) and concomitant increases with 0.45 cc and 3.98 cc in basal ovarian volume, respectively. Conclusion The AMH and AFC strongly associate with basal ovarian volume, which declines as age progresses.

Recombinant anti-Mullerian hormone treatment attenuates primordial follicle loss after ovarian cryopreservation and transplantation

PURPOSE

The foremost drawback of ovarian tissue cryopreservation and re-transplantation (OTCT) technique is the rapid loss of the primordial follicle (PF) pool. In recent studies, we have demonstrated that post-transplantation burnout of the PFs occurs due to the altered expression of the activatory and inhibitory proteins that control PF reserve, and rapamycin prevented it.

METHODS

Here, we investigated whether anti-Mullerian hormone administration in the bilateral oophorectomy and transplantation group and internal AMH in the unilateral oophorectomy and transplantation group protect follicle reserve by regulating the expression of the molecules that control follicle growth after OTCT in mice.

RESULTS

After 14 days of OTCT, PF reserve is significantly reduced in both unilateral oophorectomy and transplantation and bilateral oophorectomy and transplantation groups, while anti-Mullerian hormone treatment attenuates PF loss after bilateral oophorectomy and transplantation. The expression of KitL, Bmp-15, and p27 decreased after unilateral oophorectomy and transplantation and bilateral oophorectomy and transplantation, yet recombinant anti-Mullerian hormone treatment did not restore the expression of these proteins in the BLO-T group.

CONCLUSION

Exogenous recombinant anti-Mullerian hormone administration in the BLO-T group preserved the expressions of Tsc1 and Gdf-9 in PF and p-s6k and Gdf-9 in growing follicles after OTCT. Nonetheless, recombinant anti-Mullerian hormone administration did not affect granulosa cell proliferation and death rates in the growing follicles. These findings suggest a novel hormonal replacement strategy for fertility preservation by restoring anti-Mullerian hormone to regulate Tsc1 and p-s6k, thereby linking this hormone with the mTOR pathway and Gdf-9 signaling.

Effects of Tartrazine on Some Sexual Maturation Parameters in Immature Female Wistar Rats

Over the past century, the average age for onset of puberty has declined. Several additives present in our food are thought to contribute significantly to this early puberty which is recognized to also affect people's health in later life. On this basis, the impact of 40-days unique oral administration of the food dye tartrazine (7.5, 27, and 47 mg/kg BW doses) was evaluated on some sexual maturation parameters on immature female Wistar rats. Vaginal opening was evaluated during the treatment period. At the end of the treatments, animals were sacrificed (estrus phase) and the relative weight of reproductive organs, pituitary gonadotrophin and sexual steroids level, cholesterol level in ovaries and folliculogenesis were evaluated. Compared to the control group, animals receiving tartrazine (47 mg/kg BW) showed significantly high percentage of early vaginal opening from day 45 of age, and an increase in the number of totals, primaries, secondaries, and antral follicles; a significant increase in serum estrogen, LH and in uterine epithelial thickness. Our findings suggest that tartrazine considerably disturbs the normal courses of puberty. These results could validate at least in part the global observations on increasingly precocious puberty in girls feeding increasingly with industrially processed foods.

Two is not always greater than one: patients with one ovary have similar assisted reproductive technology (ART) outcomes compared to patients with two ovaries

PURPOSE

To assess assisted reproductive technology (ART) outcomes in patients with one ovary compared to two ovaries.

METHODS

We performed a retrospective cohort study of all patients with one ovary who underwent ≥ 1 ART cycle between 2012 and 2020 at a large university-affiliated fertility center. Patients were 3-to-1 matched with two ovary controls during the same period. Primary outcome was metaphase II oocytes (MIIs) retrieved per cycle. Secondary outcomes included ovarian reserve markers, laboratory outcomes, and live birth rates (LBRs).

RESULTS

A total of 104 one ovary patients (158 cycles; median age 35.5 years) were matched to 312 two ovary patients (474 cycles; median age 35.0 years). In one ovary patients, anti-Mullerian hormone was lower (median 1.1 vs. 2.2, p < 0.01) and day 2 follicle-stimulating hormone was higher (median 7.4 vs. 6.2, p < 0.01). One ovary patients yielded median 7.5 MIIs and 10 oocytes per cycle, fewer than two ovary patients (11.0 and 14.5, respectively; p < 0.01). However, one ovary patients had ≥ 50% the MII and oocyte yield of two ovary patients (Z > 5.8, p < 0.01). Fertilization and blastocyst formation rates, euploidy rate, and rate of ≥ 1 embryo for transfer were equivalent between groups (p > 0.40). Among the one and two ovary groups, LBRs per transfer (45.8% vs. 46.6%, p = 1.00) and per patient who underwent transfer (68.3% vs. 73.9%, p = 0.55) were equivalent.

CONCLUSION

One ovary patients yielded fewer MIIs and oocytes than two ovary patients, but had ≥ 50% the yield of two ovary patients, suggesting a compensatory mechanism in oocyte yield in the solitary ovary. One and two ovary patients had equivalent LBRs.

Live birth and pregnancy rates after in vitro fertilization/intracytoplasmic sperm injection in women with previous unilateral oophorectomy: a systematic review and meta-analysis

OBJECTIVE

To quantify the effect of unilateral oophorectomy (UO) on the rates of live birth and pregnancy in women undergoing in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).

DESIGN

Systematic review and meta-analysis.

SETTING

Search of databases of published articles.

PATIENT(S)

The final analytical cohort encompassed 1,057 IVF/ICSI cycles in women with previous UO and 45,813 IVF/ICSI cycles in control women. Eighteen studies were identified by database searches of MEDLINE, Embase, Web of Science, and cited references. The review encompassed studies published up to June 1, 2021.

INTERVENTION(S)

UO prior to IVF/ICSI.

MAIN OUTCOME MEASURE(S)

The primary outcomes were the rates of live birth and pregnancy following IVF/ICSI. The secondary outcomes included the amount of gonadotropins administered for ovarian stimulation and the number of retrieved oocytes.

RESULT(S)

The studies were rated from medium to high quality (from 5 to 8) according to the Newcastle-Ottawa Quality Assessment Scale. All studies were observational, with inherent bias, and heterogeneity was high. The primary outcome of live birth had a significantly lower odds ratio (OR) in women with previous UO compared with controls (OR = 0.72, 95% confidence interval [CI] 0.57 to 0.91, z = -2.72). The OR for pregnancy rate per initiated treatment cycle was also significantly lower in women with previous UO compared with controls (OR = 0.70, 95% CI 0.57 to 0.86, z = -3.35). Additionally, the dose of administered gonadotropins was significantly higher and the number of retrieved oocytes was significantly lower in women with UO.

CONCLUSION(S)

The meta-analysis showed a significant detrimental effect of UO on the rates of live birth and pregnancy. The analysis further supports previous data showing a decreased sensitivity to gonadotropins and a lower number of recovered oocytes in women with previous UO.

STUDY REGISTRATION NUMBER

PROSPERO 2020, CRD42020160313.

Fertility Preservation for Prepubertal Patients at Risk of Infertility: Present Status and Future Perspectives

The increasing cure rate of cancer has led to a vast population of survivors having to face the late adverse effects of oncological treatments, with fertility impairment being one of the most sensitive issues for patients. Different options to preserve the fertility of adult patients are routinely used in clinical practice. However, fertility preservation strategies for prepubertal patients at risk of infertility are limited to the cryopreservation of immature gonadal tissue. In recent decades, many research efforts have been focused on the future use of cryopreserved gonadal tissue. This review discusses the common status of fertility preservation measures for pediatric patients undergoing gonadotoxic treatment, focusing especially on the challenges that remain to be solved in order to implement this fundamental service.

Fertility Preservation: How to Preserve Ovarian Function in Children, Adolescents and Adults

Chemotherapy, pelvic radiotherapy and ovarian surgery have known gonadotoxic effects that can lead to endocrine dysfunction, cessation of ovarian endocrine activity and early depletion of the ovarian reserve, causing a risk for future fertility problems, even in children. Important determinants of this risk are the patient’s age and ovarian reserve, type of treatment and dose. When the risk of premature ovarian insufficiency is high, fertility preservation strategies must be offered to the patient. Furthermore, fertility preservation may sometimes be needed in conditions other than cancer, such as in non-malignant diseases or in patients seeking fertility preservation for personal reasons. Oocyte and/or embryo vitrification and ovarian tissue cryopreservation are the two methods currently endorsed by the American Society for Reproductive Medicine, yielding encouraging results in terms of pregnancy and live birth rates. The choice of one technique above the other depends mostly on the age and pubertal status of the patient, and personal and medical circumstances. This review focuses on the available fertility preservation techniques, their appropriateness according to patient age and their efficacy in terms of pregnancy and live birth rates.

Delayed parenthood and its influence on offspring health: What have we learned from the mouse model

Delayed parenthood is constantly increasing worldwide due to various socio-economic factors. In the last decade, a growing number of epidemiological studies have suggested a link between advanced parental age and an increased risk of diseases in the offspring. Also, poor reproductive outcome has been described in pregnancies conceived by aged parents. Similarly, animal studies showed that aging negatively affects gametes, early embryonic development, pregnancy progression and the postnatal phenotype of resulting offspring. However, how and to what extent parental age is a risk factor for the health of future generations is still subject to debate. Notwithstanding the limitation of an animal model, the mouse model represents a useful tool to understand not only the influence of parental age on offspring phenotype but also the biological mechanisms underlying the poor reproductive outcome and the occurrence of diseases in the descendants. The present review aims at i) providing an overview of the current knowledge from mouse model about the risks associated with conception at advanced age (e.g. neurodevelopmental and metabolic disorders), ii) highlighting the candidate biological mechanisms underlying this phenomenon, and iii) discussing on how murine-derived data can be relevant to humans.

Breast Cancer Risk Factors and Circulating Anti-Müllerian Hormone Concentration in Healthy Premenopausal Women

CONTEXT

We previously reported that anti-Müllerian hormone (AMH), a marker of ovarian reserve, is positively associated with breast cancer risk, consistent with other studies.

OBJECTIVE

This study assessed whether risk factors for breast cancer are correlates of AMH concentration.

METHODS

This cross-sectional study included 3831 healthy premenopausal women (aged 21-57, 87% aged 35-49) from 10 cohort studies among the general population.

RESULTS

Adjusting for age and cohort, AMH positively associated with age at menarche (P < 0.0001) and parity (P = 0.0008) and inversely associated with hysterectomy/partial oophorectomy (P = 0.0008). Compared with women of normal weight, AMH was lower (relative geometric mean difference 27%, P < 0.0001) among women who were obese. Current oral contraceptive (OC) use and current/former smoking were associated with lower AMH concentration than never use (40% and 12% lower, respectively, P < 0.0001). We observed higher AMH concentrations among women who had had a benign breast biopsy (15% higher, P = 0.03), a surrogate for benign breast disease, an association that has not been reported. In analyses stratified by age (<40 vs ≥40), associations of AMH with body mass index and OCs were similar in younger and older women, while associations with the other factors (menarche, parity, hysterectomy/partial oophorectomy, smoking, and benign breast biopsy) were limited to women ≥40 (P-interaction < 0.05).

CONCLUSION

This is the largest study of AMH and breast cancer risk factors among women from the general population (not presenting with infertility), and it suggests that most associations are limited to women over 40, who are approaching menopause and whose AMH concentration is declining.

Whole Ovary Immunofluorescence, Clearing, and Multiphoton Microscopy for Quantitative 3D Analysis of the Developing Ovarian Reserve in Mouse

Female fertility and reproductive lifespan depend on the quality and quantity of the ovarian oocyte reserve. An estimated 80% of female germ cells entering meiotic prophase I are eliminated during Fetal Oocyte Attrition (FOA) and the first week of postnatal life. Three major mechanisms regulate the number of oocytes that survive during development and establish the ovarian reserve in females entering puberty. In the first wave of oocyte loss, 30-50% of the oocytes are eliminated during early FOA, a phenomenon that is attributed to high Long interspersed nuclear element-1 (LINE-1) expression. The second wave of oocyte loss is the elimination of oocytes with meiotic defects by a meiotic quality checkpoint. The third wave of oocyte loss occurs perinatally during primordial follicle formation when some oocytes fail to form follicles. It remains unclear what regulates each of these three waves of oocyte loss and how they shape the ovarian reserve in either mice or humans. Immunofluorescence and 3D visualization have opened a new avenue to image and analyze oocyte development in the context of the whole ovary rather than in less informative 2D sections. This article provides a comprehensive protocol for whole ovary immunostaining and optical clearing, yielding preparations for imaging using multiphoton microscopy and 3D modeling using commercially available software. It shows how this method can be used to show the dynamics of oocyte attrition during ovarian development in C57BL/6J mice and quantify oocyte loss during the three waves of oocyte elimination. This protocol can be applied to prenatal and early postnatal ovaries for oocyte visualization and quantification, as well as other quantitative approaches. Importantly, the protocol was strategically developed to accommodate high-throughput, reliable, and repeatable processing that can meet the needs in toxicology, clinical diagnostics, and genomic assays of ovarian function.

Could hormonal and follicular rearrangements explain timely menopause in unilaterally oophorectomized women?

STUDY QUESTION

Does unilateral oophorectomy modify the relationship between serum anti-Müllerian hormone (AMH) levels and antral follicle count (AFC)?

SUMMARY ANSWER

No altered 'per-ovary' and 'per-follicle' AMH production and antral follicle distribution was evident in unilaterally oophorectomized women compared to matched controls.

WHAT IS KNOWN ALREADY

The age of menopause onset is relatively unchanged in patients having undergone unilateral oophorectomy. Mechanisms that occur to preserve and maintain ovarian function in this context remain to be elucidated.

STUDY DESIGN, SIZE, DURATION

Forty-one infertile women, with no polycystic ovary syndrome (PCOS) and no endometriosis, aged 19-42 years old, having undergone unilateral oophorectomy (One Ovary group; average time since surgery: 23.8 ± 2.2 months) were retrospectively age-matched (±1 year) with 205 infertile women having two intact ovaries and similar clinical features (Control group).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serum AMH levels, 3-4 mm AFC, 5-12 mm AFC, and total AFC (3-12 mm) were assessed on cycle Day 3 in both groups. Hormonal and ultrasonographic measurements obtained from patients in the Control group (i.e. having two ovaries) were divided by two to be compared with measurements obtained from patients of the One Ovary group (i.e. having one single remaining ovary). To estimate per-follicle AMH production, we calculated the ratio between serum AMH levels over 3-4 mm AFC, 5-12 mm AFC, and total AFC (3-12 mm), and the strength of the correlation between serum AMH levels and total AFC. The main outcome measure was to assess Day 3 AMH/Day 3 AFC ratio and hormonal-follicular correlation.

MAIN RESULTS AND THE ROLE OF CHANCE

As expected, before correction, mean serum AMH levels (1.46 ± 0.2 vs 2.77 ± 0.1 ng/ml, P < 0.001) and total AFC (7.3 ± 0.6 vs 15.1 ± 0.4 follicles, P < 0.0001) were lower in the One Ovary group compared to the Control group, respectively. Yet, after correction, per-ovary AMH levels (1.46 ± 0.2 vs 1.39 ± 0.1 ng/ml) and total AFC (7.3 ± 0.6 vs 7.5 ± 0.2 follicles) values were comparable between the two groups. Consistently, per-follicle AMH levels (3-4 mm, 5-12 mm, and total) were not significantly different between the two groups (0.39 ± 0.05 vs 0.37 ± 0.02 ng/ml/follicle; 0.69 ± 0.12 vs 0.59 ± 0.05 ng/ml/follicle, and 0.23 ± 0.03 vs 0.19 ± 0.01 ng/ml/follicle; respectively). In addition, the prevalence of 3-4 mm follicles was comparable between the two groups (66.7% for One Ovary group vs 58.8% for Control group, respectively). Finally, the correlation between serum AMH levels and total AFC was similar for patients in the One Ovary group (r = 0.70; P < 0.0001) compared to those in the Control group (r = 0.68; P < 0.0001).

LIMITATIONS/REASONS FOR CAUTION

The retrospective character of the analysis might lead to potential bias.

WIDER IMPLICATIONS OF THE FINDINGS

The present investigation did not provide evidence of altered 'per-ovary' and 'per-follicle' AMH production and antral follicle distribution in unilaterally oophorectomized women compared to matched controls. Further studies are warranted to support the hypothesis that follicle-sparing mechanisms are clearly at stake in remaining ovaries after unilateral oophorectomy to explain their long-lasting function and timely menopausal onset.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no funding or competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review

The optimal time interval between myomectomy and pregnancy is unclear and no specific guidelines exist. The aim of this review was to study the time interval from myomectomy to pregnancy and the occurrence of uterine rupture after myomectomy. Randomized controlled trials, cohort studies and retrospective studies were used to assess the primary objective, and case reports, cases series or letters to the editor for the secondary objective. Only articles reporting myomectomy performed via the vaginal route, laparotomy, laparoscopy or robot-assisted surgery were selected for inclusion. Among 3852 women who wanted to become pregnant after the surgery, 2889 became pregnant, accounting for 3000 pregnancies (77.9%) and 2097 live births (54.4%). Mean time between myomectomy and pregnancy was estimated at 17.6 months (SD 9.2) for 2451 pregnant women. Among 1016 women, a third were advised to delay attempting to conceive for between 3 and 6 months and another third for between 6 and 12 months. A total of 70 spontaneous uterine ruptures with a mean gestational age of 31 weeks at occurrence were identified. No linear relationship was found between gestational age at the event and time interval from myomectomy to conception (P = 0.706). There are insufficient data to advise a minimal time interval between myomectomy and conception.

Dingkun Pill replenishes diminished ovarian reserve through the PI3K/AKT/mTOR signaling pathway in TWP-induced mice

ETHNOPHARMACOLOGICAL RELEVANCE

Diminished ovarian reserve (DOR) can lead to poor fertility and shorten the reproductive lifespan of females. The Dingkun Pill (DKP), a traditional Chinese-patented medication, has been an integral part of traditional Chinese medicinal treatment for the management of gynecological diseases for centuries. Relevant clinical studies have shown that DKP is able to protect against DOR, however, its mechanism of action is not yet fully elucidated.

STUDY GOALS

This study was conducted with the aim of exploring the impact of tripterygium wilfordii polyglycosidium (TWP) on the PI3K/AKT/mTOR pathway in the context of the pathophysiology of DOR and the mechanism of action of DKP.

MATERIALS AND METHODS

Eighty female balb/c mice with regular estrous cycles were assigned to Blank, Model, DKP and hormone replacement therapy (HRT) groups in a random manner. With the exception of the Blank group, mice in the other groups were exposed to 40 mg/kg/d TWP suspension for 30 days to DOR induction. Following this, either DKP or hormones were orally administrated to determine their effect on disease progression. During the experiment, changes in body weight and the estrous cycles of the mice were observed. Post treatment, serum sample anti-mullerian hormone (AMH), estradiol (E₂), luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels were quantified using enzyme-linked immunosorbent assay (ELISA). The mice were then sacrificed in order to harvest their ovaries for hematoxylin and eosin (HE) staining. This process allowed for the assessment of ovarian morphology and follicular quantification. Apoptotic ovarian cells of the ovary were assessed using TUNEL technique, while Caspase-3 and Cytochrome C (Cyt C) expressions of the ovary were examined through immunohistochemistry (IHC). Western blotting analysis was used to quantify levels of Bax, Bcl-2, Caspase-3, Cyt C, mTOR, P-mTOR, AKT, P-AKT, P-PI3K and PI3K proteins, while mRNA levels of Bax, Bcl-2, PI3K, AKT and mTOR were measured in ovarian tissue using RT-PCR.

RESULTS

The findings revealed that DKP was able to improve levels of serum hormones and promote the recovery of the estrous cycle. DKP augmented the total amount of primordial follicles while reducing the number of follicles that were atretic follicles. The apoptosis index of growing follicles and Bax, Cyt C and Caspase-3 expressions decreased, while the Bcl-2: Bax ratio increased. DKP suppressed levels of phosphorylation and the mRNA expressions of mTOR, AKT and PI3K.

CONCLUSIONS

It was demonstrated that DKP was able to increase ovarian reserves through inhibition of the PI3K/AKT/mTOR signaling pathway, which lead to the suppression of primordial follicle activity and a reduction in levels of apoptosis of early growing follicles. This highlights its potentially beneficial role for the treatment of DOR.

Spatial and temporal changes in follicle distribution in the human ovarian cortex

RESEARCH QUESTION

How does follicle distribution evolve in the human ovarian cortex between the ages of 20 and 35 years?

DESIGN

Fragments of ovarian cortex from women undergoing unilateral oophorectomy for fertility preservation were obtained for quantitative histological assessment, including recording the two-dimensional coordinates of the follicles. Data were analysed using spatial statistical methods.

RESULTS

A total of 53 ovarian cortex tissue samples, containing 1-803 follicles each, were obtained from 14 women aged 20-35 years. Primordial and transitory follicles lay in a clustered manner in the human ovarian cortex, with an average cluster radius of around 270 µm (95% confidence interval 154-377 µm; n = 49). Follicle density declined with age (P = 0.006, n = 13), and the distance from the nearest neighbouring follicle increased (P = 0.004, n = 13). Cluster radius decreased with age (P = 0.02, n = 13), but the degree of clustering tended to increase (P = 0.11, n = 13). In the majority of the samples, follicles at different stages lay in different clusters (P < 0.05, n = 13).

CONCLUSIONS

This study shows that primordial and transitory follicles lie in different clusters in the human ovarian cortex. Spatio-temporal computer simulation suggests that interfollicular signals may hinder follicle loss and may therefore drive clustered follicle distribution. In clinical practice, the woman's age should be taken into account when assessing follicle density, as follicle distribution is increasingly clustered with advancing age.

Biological Impact of Unilateral Oophorectomy: Does the Number of Ovaries Really Matter?

Although unilateral oophorectomies are performed more often than bilateral ones in women of reproductive age, their clinical consequences have been less intensively investigated. Experimental models in animals have shown that compensatory mechanisms occur after a unilateral oophorectomy (UO). This review aims to summarize the available evidence on the biological effects of unilateral oophorectomy on women. Evaluated outcomes include age at onset of menopause, risk of cardiovascular and neurological disease, risk of mortality and fertility outcome after spontaneous conception or in vitro fertilization (IVF). Results were compared with findings reported after bilateral oophorectomy and/or ovarian excision and/or women with intact ovaries. An electronic database search was performed using PubMed and Scopus, followed by a manual search to identify controlled studies that compared women after UO with women with two intact ovaries. In particular, a systematic review of fertility outcomes after IVF was performed, and the data were summarized in a table. Women who underwent UO had a similar age at menopause and similar clinical pregnancy rate compared to women with two ovaries. However, decreased ovarian reserve affecting the quantity but not the quality of the ovarian pool after IVF was observed in the UO group. Furthermore, an increased risk of neurological disease and even an increased risk of mortality was observed in women with single ovary. These data need to be confirmed by further studies, and a plausible mechanism of action must be identified. At present, patients who undergo UO can be reassured with regard to their reproductive potential and their age at onset of menopause.

Delay in IVF treatment up to 180 days does not affect pregnancy outcomes in women with diminished ovarian reserve

STUDY QUESTION

Will a delay in initiating IVF treatment affect pregnancy outcomes in infertile women with diminished ovarian reserve?

SUMMARY ANSWER

A delay in IVF treatment up to 180 days does not affect the live birth rate for women with diminished ovarian reserve when compared to women who initiate IVF treatment within 90 days of presentation.

WHAT IS KNOWN ALREADY

In clinical practice, treatment delays can occur due to medical, logistical or financial reasons. Over a period of years, a gradual decline in ovarian reserve occurs which can result in declining outcomes in response to IVF treatment over time. There is disagreement among reproductive endocrinologists about whether delaying IVF treatment for a few months can negatively affect patient outcomes.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of infertile patients in an academic hospital setting with diminished ovarian reserve who started an IVF cycle within 180 days of their initial consultation and underwent an oocyte retrieval with planned fresh embryo transfer between 1 January 2012 and 31 December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Diminished ovarian reserve was defined as an anti-Müllerian hormone (AMH) <1.1 ng/ml. In total, 1790 patients met inclusion criteria (1115 immediate and 675 delayed treatment). Each patient had one included cycle and no subsequent data from additional frozen embryo transfer cycles were included. Since all cycle outcomes evaluated were from fresh embryo transfers, no genetically tested embryos were included. Patients were grouped by whether their cycle started 1-90 days after presentation (immediate) or 91-180 days (delayed). The primary outcome was live birth (≥24 weeks of gestation). A subgroup analysis of more severe forms of diminished ovarian reserve was performed to evaluate outcomes for patients with an AMH <0.5 and for patients >40 years old with an AMH <1.1 ng/ml (Bologna criteria for diminished ovarian reserve). Logistic regression analysis, adjusted a priori for patient age, was used to estimate the odds ratio (OR) with a 95% CI. All pregnancy outcomes were additionally adjusted for the number of embryos transferred.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean ± SD number of days from presentation to IVF start was 50.5 ± 21.9 (immediate) and 128.8 ± 25.9 (delayed). After embryo transfer, the live birth rate was similar between groups (immediate: 23.9%; delayed: 25.6%; OR 1.08, 95% CI 0.85-1.38). Additionally, a similar live birth rate was observed in a subgroup analysis of patients with an AMH <0.5 ng/ml (immediate: 18.8%; delayed: 19.1%; OR 0.99, 95% CI 0.65-1.51) and in patients >40 years old with an AMH <1.1 ng/ml (immediate: 12.3%; delayed: 14.7%; OR 1.21, 95% CI 0.77-1.91).

LIMITATIONS, REASONS FOR CAUTION

There is the potential for selection bias with regard to the patients who started their IVF cycle within 90 days compared to 91-180 days after initial consultation. In addition, we did not include patients who were seen for initial evaluation but did not progress to IVF treatment with oocyte retrieval; therefore, our results should only be applied to patients with diminished ovarian reserve who complete an IVF cycle. Finally, since we excluded patients who started their IVF cycle greater than 180 days from their first visit, it is not known how such a delay in treatment affects pregnancy outcomes in IVF cycles.

WIDER IMPLICATIONS OF THE FINDINGS

A delay in initiating IVF treatment in patients with diminished ovarian reserve up to 180 days from the initial visit does not affect pregnancy outcomes. This observation remains true for patients who are in the high-risk categories for poor response to ovarian stimulation. Providers and patients should be reassured that when a short-term treatment delay is deemed necessary for medical, logistic or financial reasons, treatment outcomes will not be affected.

STUDY FUNDING/COMPETING INTEREST(S)

No financial support, funding or services were obtained for this study. The authors do not report any potential conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Ability of human umbilical cord mesenchymal stem cells to repair chemotherapy-induced premature ovarian failure

BACKGROUND

Premature ovarian insufficiency (POI) and premature ovarian failure (POF) have become one of the major problems threatening women of childbearing age. Studies have shown that stem cells transplanted from bone marrow, umbilical cord, peripheral blood and amniotic fluid can migrate and proliferate to the ovary, promote ovarian function repair, increase the number of follicles and granulosa cells at all levels of ovary, improve endocrine function, and can differentiate into oocytes in specific ovarian environment to restore fertility to some extent.

AIM

To study the ability of human umbilical cord mesenchymal stem cells (hUCMSCs) to repair ovarian injury after chemotherapy.

METHODS

A total of 110 female BALB/c mice (aged 7-8 wk old) with body masses of 16.0-20.0 g were selected. The mice were fed until 12 wk of age, and cyclophosphamide was administered by intraperitoneal injection for 14 consecutive days to induce premature ovarian failure in mice. Seventy-five mice with estrous cycle disorder were screened and randomly divided into 3 groups according to their body weight: model group, positive control group and hUCMSC group, and each group had 25 mice. Another 25 mice were used as negative controls. The mice in the hUCMSC group were injected with hUCMSCs in the tail vein, and the mice in the positive control group were given an oestradiol valerate solution and a medroxyprogesterone acetate solution in the tail vein. On the 1^st, 15^th, 30^th, 45^th, and 60^th days after intravenous administration, vaginal smears were made to monitor the estrous cycles of the mice. The ovaries were weighed, and pathological sections were made to observe the morphology of the follicles; blood samples were collected to monitor the concentration of sex hormones (oestradiol and follicle-stimulating hormone).

RESULTS

The estrous cycles of the model group mice were disrupted throughout the experiment. Mice in the hUCMSC group and the positive control group resumed normal estrous cycles. The ovarian weight of the model group mice continued to decline. The ovarian weight of the hUCMSC group mice and the positive control group mice decreased first and then gradually increased, and the ovarian weight of the hUCMSC group mice was heavier than that of the positive control group mice. The difference was statistically significant (P < 0.05). Compared with the negative control group, the model group experienced a decrease in oestradiol and an increase in follicle-stimulating hormone, and the difference was statistically significant (P < 0.05). Compared with the model group, the hUCMSC and positive control groups experienced a slight increase in oestradiol and a decrease in follicle-stimulating hormone; the difference was statistically significant (P < 0.05). The pathological examination revealed that the mouse ovaries from the model group were atrophied, the volume was reduced, the cortical and medullary structures were disordered, the number of follicles at all stages was significantly reduced, the number of atretic follicles increased, the number of primordial follicles and corpus luteum significantly decreased, and the corpus luteum had an irregular shape. Compared with those of the model group, the lesions of the hUCMSC and positive control groups significantly improved.

CONCLUSION

hUCMSCs can repair ovarian tissue damaged by chemotherapy to a certain extent, can improve the degree of apoptosis in ovarian tissue, and can improve the endocrine function of mouse ovaries.

Aging Fits the Disease Criteria of the International Classification of Diseases

The disease criteria used by the World Health Organization (WHO) were applied to human biological aging in order to assess whether aging can be classified as a disease. These criteria were developed for the 11th revision of the International Classification of Diseases (ICD) and included disease diagnostics, mechanisms, course and outcomes, known interventions, and linkage to genetic and environmental factors. RESULTS: Biological aging can be diagnosed with frailty indices, functional, blood-based biomarkers. A number of major causal mechanisms of human aging involved in various organs have been described, such as inflammation, replicative cellular senescence, immune senescence, proteostasis failures, mitochondrial dysfunctions, fibrotic propensity, hormonal aging, body composition changes, etc. We identified a number of clinically proven interventions, as well as genetic and environmental factors of aging. Therefore, aging fits the ICD-11 criteria and can be considered a disease. Our proposal was submitted to the ICD-11 Joint Task force, and this led to the inclusion of the extension code for "Ageing-related" (XT9T) into the "Causality" section of the ICD-11. This might lead to greater focus on biological aging in global health policy and might provide for more opportunities for the new therapy developers.

Rapamycin treatment maintains developmental potential of oocytes in mice and follicle reserve in human cortical fragments grafted into immune-deficient mice

The ovarian follicle pool size is limited; it decreases with age and following germ cell-damaging chemo- or radiation therapies. Due to a trend of delaying child-bearing age in the modern society, it is important to investigate the possibility to maintain the follicle reserve for middle-aged women and cancer-bearing patients subject to therapies. Earlier studies demonstrated the important role of the mammalian targets of the rapamycin (MTOR) signaling pathway in the activation of primordial follicles and suggested that treatment with the MTOR inhibitor rapamycin could maintain the follicle pool in rodents. Here, we confirmed the ability of rapamycin treatment for 3 weeks to suppress primordial follicle development and to maintain follicle pool size in mice. We further demonstrated that the developmental potential of oocytes was not affected by rapamycin treatment and the effect of rapamycin to decrease initial follicle recruitment is reversible. Using human ovarian cortical fragments grafted into immune-deficient mice, we demonstrated the ability of rapamycin to suppress follicle growth from the primordial stage. Our studies provide the basis for further studies on the possibility of using MTOR inhibitors to maintain follicle reserve in middle-aged women and cancer patients before/during germ cell-damaging therapies.

State of the Art in Fertility Preservation for Female Patients Prior to Oncologic Therapies

Quality of life improvement stands as one of the main goals of the medical sciences. Increasing cancer survival rates associated with better early detection and extended therapeutic options led to the specific modeling of patients’ choices, comprising aspects of reproductive life that correlated with the evolution of modern society, and requires better assessment. Of these, fertility preservation and ovarian function conservation for pre-menopause female oncologic patients pose a contemporary challenge due to procreation age advance in evolved societies and to the growing expectations regarding cancer treatment. Progress made in cell and tissue-freezing technologies brought hope and shed new light on the onco-fertility field. Additionally, crossing roads with general fertility and senescence studies proved highly beneficial due to the enlarged scope and better synergies and funding. We here strive to bring attention to this domain of care and to sensitize all medical specialties towards a more cohesive approach and to better communication among caregivers and patients.

Decreased ovarian function and autophagy gene methylation in aging rats

Background

Degeneration of ovarian function is an obvious feature of female aging. In addition, studies have shown that autophagy decreases with age, and DNA methylation is a hallmark epigenetic pattern during aging. However, it is not clear whether the expression and DNA methylation of autophagy genes are involved in the declines in ovarian function that occur during aging.

Results

Three groups of rats were used: 6-month-old (6 M) rats, 12-month-old (12 M) rats and 24-month-old (24 M) rats. Serum E₂ levels and the mRNA and protein expression levels of Atg5, Atg12, Atg16L, Beclin1 and Lc3B were significantly decreased in aged rats. In addition, the methylation levels of the Atg5 gene were significantly increased in aged rats. The expression of the Dnmt1 and Dnmt2 genes decreased with aging; however, the expression of the Dnmt3A and Dnmt3B genes gradually increased with aging.

Conclusions

Decreased autophagic activity was involved in the declines in ovarian function in aging rats. Upregulation of the DNA methyltransferases Dnmt3A and Dnmt3B may have led to methylation of the autophagy genes Atg5 and Lc3B to ultimately cause the observed decreases in autophagic activity.

Progress in Fertility Preservation Strategies in Turner Syndrome

Growth retardation and gonadal dysgenesis are two of the most important clinical manifestations of Turner syndrome (TS). As premature ovarian failure generally occurs early in life in women with TS, these patients should be counseled and evaluated as early as possible for discussion of optimal and individualized fertility preservation strategies. Infertility seriously affects the quality of life of women with TS. For those who have ovarian reserve, the theoretical options for future fertility in TS patients include cryopreservation of oocytes, ovarian tissues, and embryos. For those who have already lost their ovarian reserve, oocyte or embryo donation, gestational surrogacy, and adoption are strategies that allow fulfillment of desire for parenting. This review describes the etiologies of infertility and reviews the fertility preservation strategies for women with TS.

Consequences of chemotherapeutic agents on primordial follicles and future clinical applications

The ovarian reserve is necessary for female fertility and endocrine health. Commonly used cancer therapies diminish the ovarian reserve, thus, resulting in primary ovarian insufficiency, which clinically presents as infertility and endocrine dysfunction. Prepubertal children who have undergone cancer therapies often experience delayed puberty or cannot initiate puberty and require endocrine support to maintain a normal life. Thus, developing an effective intervention to prevent loss of the ovarian reserve is an unmet need for these cancer patients. The selection of adjuvant therapies to protect the ovarian reserve against cancer therapies underlies the mechanism of loss of primordial follicles (PFs). Several theories have been proposed to explain the loss of PFs. The "burn out" theory postulates that chemotherapeutic agents activate dormant PFs through an activation pathway. Another theory posits that chemotherapeutic agents destroy PFs through an "apoptotic pathway" due to high sensitivity to DNA damage. However, the mechanisms causing loss of the ovarian reserve remains largely speculative. Here, we review current literature in this area and consider the mechanisms of how gonadotoxic therapies deplete PFs in the ovarian reserve.

Maternal nutrient restriction impairs young adult offspring ovarian signaling resulting in reproductive dysfunction and follicle loss

Reproductive abnormalities are included as health complications in offspring exposed to poor prenatal nutrition. We have previously shown in a rodent model that offspring born to nutrient restriction during pregnancy are born small, enter puberty early, and display characteristics of early ovarian aging as adults. The present study investigated whether key proteins involved in follicle recruitment and growth mediate ovarian follicle loss. Pregnant rats were randomized to a standard diet throughout pregnancy and lactation (CON), or a calorie-restricted (50% of control) diet (UN) during pregnancy. Offspring reproductive phenotype was investigated at postnatal days 4, 27, and 65. Maternal UN resulted in young adult (P65) irregular estrous cyclicity due to persistent estrus, a significant loss of antral follicles, corpora lutea, and an increase in atretic follicles. This decrease in growing follicles in UN offspring appears to be due to increased apoptosis as seen by immunopositive staining of pro-apoptotic factor CASP3 (caspase 3) in ovaries of young adult offspring. UN prepubertal offspring had reduced expression levels of Fshr in antral follicles, which may contribute to a decrease in PI3K/AKT activation evident as a decrease in pAKT immunolocalization in prepubertal antral follicles. Moreover, neonatal ovaries of UN offspring show decreased levels of immunopositive staining for AMHR2 (anti-mullerian hormone receptor 2). Collectively, these data demonstrate that maternal UN during pregnancy impacts ovarian function in offspring as early as P65 and provides a model for understanding the mechanisms driving early life UN-induced follicle loss and reproductive dysfunction.

Fertility preservation in women with cancer and afterward

Women are surviving cancer in greater numbers. For this population, fertility becomes an important issue to be discussed before treatment to ensure maximal chances of fertility after treatment completion. Options for fertility preservation include egg or embryo freezing, ovarian tissue freezing, as well as gonadotropin releasing hormone analogs. The option for each individual patient will depend on the type of cancer, its aggressiveness and the time before treatment needs to commence, the type of treatment, the health of the patient, and whether the patient has a male partner.

Successful pregnancy with tripterygium glycoside-induced premature ovarian insufficiency: a case report

Premature ovarian insufficiency is characterized by reduced ovarian function in a young woman, resulting in an earlier menopause compared with women with normal ovarian function. It is a term that reflects the variable nature of the condition and is substantially less emotive than the formerly used ‘premature ovarian failure’, which suggested a single event in time. Tripterygium glycosides can damage ovarian function and cause infertility. This case report describes a 33-year-old female patient (gravida 0, parity 0) who presented with premature ovarian insufficiency after being treated with tripterygium glycosides for nephrotic syndrome. The woman received oestrogen-progestin replacement therapy (Femoston) and ovulation induction, which resulted in a successful pregnancy. The patient delivered a healthy baby girl. This case demonstrates that it is possible for a woman with tripterygium glycoside-induced premature ovarian insufficiency to become pregnant with the correct therapy.

Antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) are the predictors of natural fecundability have similar trends irrespective of fertility status and menstrual characteristics among fertile and infertile women below the age of 40 years

BACKGROUND

Despite being born with a significant number of primordial cells which representing the ancestor cells of the germ-line, women experience a depletion of ovarian reserve and sub-fertility mid-way into their healthy lives. The poor ovarian response is a substantial limiting factor amplified with higher maternal age and associated with a considerably lower likelihood of pregnancy.

METHODS

A present analytical prospective cross-sectional study was conducted to explore whether infertile women below the age of 40 years have low ovarian reserve than fertile women of same age, assessed by Antral follicle count (AFC) and anti-Müllerian hormone (AMH), at tertiary care infertility center: Lahore Institute of Fertility and Endocrinology, Hameed Latif Hospital. The study population including 423 infertile and 388 fertile female patients from June 2013 to November 2016. Patients and controls were aged between 25 and 39 years. Serum levels of FSH, LH, AMH were assessed, and AFC was measured by transvaginal sonography on cycle days 2 or 3.

RESULTS

A total of 35.6% of infertile women stated a menstrual cycle length shorter than 21 days, while 21% had a regular cycle length between 24 and 38 days, and 43.2%, longer than 38 days. Overall, the two cohorts did not significantly differ on cycle length. The age-specific reduction of the ovarian reserve was similar in both cohorts; serum AMH concentration decreased by 6% (95% Cl: 5-8%) and AFC decline by 4.5% (95% Cl: 5-7%) per year with increased age. Aged patients (36-39 years) had a 5.3% (95% Cl, 1.5; 7.2) higher risk ratio of having an AMH level < 0.7 ng/ml than women of younger age groups (Kruskal-Wallis test, p < 0.01).

CONCLUSION

This study indicates that the possible common observation of low respondent in ART might not be a result of over-representation of patients with an early age-specific decline in the ovarian reserve, but rather primarily as a consequence of age-specific depletion in the stock of developing follicles at the time of recruitment and selection.

Fertility and reproductive care in chronic kidney disease

In both women and men, chronic kidney disease (CKD) is associated with decreased fertility. Though a multitude of factors contribute to the reduction in fertility in this population, progressively impaired function of the hypothalamic-pituitary-gonadal axis appears to play a key role in the pathophysiology. There is limited research on strategies to manage infertility in the CKD population, but intensive hemodialysis, kidney transplantation, medication management and assisted reproductive technologies (ART) have all been proposed. Though fertility and reproductive care are reported as important elements of care by CKD patients themselves, few nephrology clinicians routinely address fertility and reproductive care in clinical interactions. Globally, the average age of parenthood is increasing, with concurrent growth and expansion in the use of ART. Coupled with an increasing prevalence of CKD in women and men of reproductive age, the importance of understanding fertility and reproductive technologies in this population is highlighted. This review endeavors to explore the female and male factors that affect fertility in the CKD population, as well as the evidence supporting strategies for reproductive care.

Ovarian function and reproductive senescence in the rat: role of ovarian sympathetic innervation

Successful reproduction is the result of a myriad interactions in which the ovary and the ovarian follicular reserve play a fundamental role. At present, women who delay maternity until after 30 years of age have a decreased fertility rate due to various causes, including damaged follicles and a reduction in the reserve pool of follicles. Therefore, the period just prior to menopause, also known as the subfertile period, is important. The possibility of modulating the follicular pool and the health of follicles during this period to improve fertility is worth exploring. We have developed an animal model to study the ovarian ageing process during this subfertile period to understand the mechanisms responsible for reproductive senescence. In the rat model, we have shown that the sympathetic nervous system participates in regulating the follicular development during ovarian ageing. This article reviews the existing evidence on the presence and functional role of sympathetic nerve activity in regulating the follicular development during ovarian ageing, with a focus on the subfertile period.

Free Spanish abstract: A Spanish translation of this abstract is freely available athttp://www.reproduction-online.org/content/153/2/R59/suppl/DC1.

Neonatal overfeeding induces early decline of the ovarian reserve: Implications for the role of leptin

Early life nutrition is crucial for reproduction. Overweight and obese girls are more likely to experience early menarche, increasing the risk of adult disease. We have previously demonstrated neonatal overfeeding in the rat leads to accelerated growth, early puberty and increased circulating levels of leptin, an adipocyte-derived hormone that regulates puberty. However, the long-term consequences of accelerated puberty and metabolic dysfunction on ovarian reserve are unknown. Here we show that neonatal overfeeding reduced the number of ovarian follicles in adult rats; specifically, the primordial follicle pool was reduced compared to controls. The reduction of ovarian reserve coincided with a diminished release of pituitary gonadotropins at ovulation and altered expression of ovarian markers important for follicular recruitment and survival. These changes were associated with increased levels of ovarian leptin and its receptor. Postnatal administration of leptin antagonist did not reverse the weight gain induced by early life overfeeding, but rescued the decline in the primordial follicle pool and abolished the differences in circulating leptin and gonadotropins. Our findings suggest that the acute effects of elevated circulating leptin may be responsible for the long-term reproductive outcomes after neonatal overfeeding, leading to premature ovarian ageing and changes in reproductive efficiency.