TRADITIONAL CHINESE MEDICINE COMBINED WITH HORMONE THERAPY TO TREAT PREMATURE OVARIAN FAILURE: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Selected plant extracts and female fertility: role in the regulation of the hypothalamo-pituitary-ovarian axis in normal and pathological conditions

Female infertility, which affects 10-20% of couples worldwide, is a growing health concern in developing countries. It can be caused by multiple factors, including reproductive disorders, hormonal dysfunctions, congenital malformations and infections. In vitro and in vivo studies have shown that plant extracts regulate gonadotropin-releasing hormone, kisspeptin, and gonadotropin expression and/or secretion at the hypothalamic-pituitary level and modulate somatic and germ cells, such as steroidogenesis, proliferation, apoptosis, and oxidative stress at the ovarian level. In this review, we report evidence for the role of certain plant extracts or plant bioactive compounds in the regulation of the hypothalamic-pituitary-ovary axis and, consequently, for the treatment of female infertility. We will also summarize their possible involvement in ovarian disorders such as polycystic ovary syndrome (PCOS), premature ovarian failure (POF) and ovarian cancers.

Efficacy and Clinical Significance of the Zuogui Pill on Premature Ovarian Failure via the GDF-9/Smad2 Pathway

Our study aims to investigate the efficacy and clinical significance of the Zuogui pill (ZGP) on premature ovarian failure (POF) via the GDF-9/Smad2 pathway. Changes in clinical symptoms in the control group (treated with Femoston alone) and the treatment group (treated with ZGP combined with Femoston) were assessed before and after treatment. Sex hormone levels, serum inflammatory cytokine levels, and ultrasound parameters were measured before and after treatment. POF rat models were established using cyclophosphamide and the POF rats were treated with Femoston, or ZGP combined with Femoston. GDF-9 and Smad2 expression levels were determined by RT-qPCR. The follicle-stimulating hormone (FSH), luteinizing hormone (LH), interleukin (IL)-6, and IL-21 levels, and the pulsatility index (PI) and resistance index (RI) values were decreased, while the estradiol (E2) and anti-Mullerian hormone (AMH) levels, antral follicle count (AFC), ovarian volume (OV), mean ovarian diameter (MOD), and peak systolic velocity (PSV) values were increased in the treatment group compared to the control group. After treatment with ZGP combined with Femoston, GDF-9 and Smad2 expression in the ovarian tissues of POF rats increased. ZGP has a therapeutic effect on POF via modulation of the GDF-9/Smad2 pathway.

Bone marrow mesenchymal stem cells in premature ovarian failure: Mechanisms and prospects

Premature ovarian failure (POF) is a common female reproductive disorder and characterized by menopause, increased gonadotropin levels and estrogen deficiency before the age of 40 years old. The etiologies and pathogenesis of POF are not fully clear. At present, hormone replacement therapy (HRT) is the main treatment options for POF. It helps to ameliorate perimenopausal symptoms and related health risks, but can't restore ovarian function and fertility fundamentally. With the development of regenerative medicine, bone marrow mesenchymal stem cells (BMSCs) have shown great potential for the recovery of ovarian function and fertility based on the advantages of abundant sources, high capacity for self-renewal and differentiation, low immunogenicity and less ethical considerations. This systematic review aims to summarize the possible therapeutic mechanisms of BMSCs for POF. A detailed search strategy of preclinical studies and clinical trials on BMSCs and POF was performed on PubMed, MEDLINE, Web of Science and Embase database. A total of 21 studies were included in this review. Although the standardization of BMSCs need more explorations, there is no doubt that BMSCs transplantation may represent a prospective therapy for POF. It is hope to provide a theoretical basis for further research and treatment for 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 Effects of Low-Intensity Pulsed Ultrasound on Premature Ovarian Insufficiency

We explored the therapeutic effects of low-intensity pulsed ultrasound (LIPUS) on a rat model of ovarian damage induced by cyclophosphamide. A total of 44 female rats with premature ovarian insufficiency induced by cyclophosphamide were randomly divided into two groups (an ultrasound group and a control group); 22 normal rats without premature ovarian insufficiency were also included as a third group. The ultrasound group was treated with LIPUS, while the other two groups received the same treatment but without any power output. We monitored the estrous cycles of all rats. Seven days after treatment, 21 rats were selected to mate with male rats. We then recorded the pregnancy rate along with the number and weight of newborn rats per nest. We collected samples of blood, uterus and ovaries from the remaining 45 rats before they were sacrificed. Compared with the normal group, the control group exhibited disordered estrous cycles, more atretic follicles (p < 0.01), higher levels of serum follicle-stimulating hormone (p < 0.01), fewer other follicles (p < 0.01) and lower serum levels of E₂ and anti-Müllerian hormone (p < 0.01). Compared with the control group, the ultrasound group had normal estrous cycles with fewer atretic follicles (p < 0.01), lower levels of serum follicle-stimulating hormone (p < 0.01), more other follicles (p < 0.01) and higher levels of serum E₂ (p < 0.01). No significant difference in the levels of serum anti-Müllerian hormone was noted between the control group and the ultrasound group. No significant differences were observed between the three groups with respect to pregnancy rate or the number and weight of newborns per nest (p > 0.05). In conclusion, our data indicate that LIPUS could improve some ovarian functions of rats with premature ovarian insufficiency.

Evidence of TCM Theory in Treating the Same Disease with Different Methods: Treatment of Pneumonia with Ephedra sinica and Scutellariae Radix as an Example

Pneumonia is a serious global health problem and the leading cause of mortality in children. Antibiotics are the main treatment for bacterial pneumonia, but there are serious drug resistance problems. Traditional Chinese medicine (TCM) has been used to treat diseases for thousands of years and has a unique theory. This article takes the treatment of pneumonia with Ephedra sinica as a representative hot medicine and Scutellariae Radix as a representative cold medicine as an example. We explore and explain the theory of treating the same disease with different TCM treatments. Using transcriptomics and network pharmacology methods, GO, KEGG enrichment, and PPI network construction were carried out, demonstrating that Ephedra sinica plays a therapeutic role through the NF-κB and apoptosis signaling pathways targeting PLAU, CD40LG, BLC2L1, CASP7, and CXCL8. The targets of Scutellariae Radix through the IL-17 signaling pathway are MMP9, CXCL8, and MAPK14. Molecular docking technology was also used to verify the results. In short, our results provide evidence for the theory of treating the same disease with different treatments, and we also discuss future directions for traditional Chinese medicine.

Kuntai capsule attenuates premature ovarian failure through the PI3K/AKT/mTOR pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Kuntai capsule (KTC), a type of herb formulas, was first described in the book of Shang Han Za Bing Lun in the third century. KTC has been widely used for the clinical treatment of menopausal syndrome. Considering that premature ovarian failure is also known as premature menopause, this study was designed to investigate the effects and mechanisms of KTC on a mouse model of premature ovarian failure.

MATERIALS AND METHODS

Forty-five female C57BL/6 mice were chosen for this study. Fifteen of the mice were separated into the Control group. The remaining thirty were used to establish the premature ovarian failure model by injecting intraperitoneally with 75 mg/kg cyclophosphamide and then by randomly dividing the mice into two groups. One group was considered the Model group, the other group treated with the Kuntai capsule intragastrically every day for one week called the KTC group. After treatment, mice were sacrificed for sampling. The ovaries morphology of mice was observed by hematoxylin and eosin (HE) staining, and all follicles were counted under microscope. Western blotting was used to detect the PI3K/AKT/mTOR pathway activation. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) and anti-mullerian hormone (AMH)levels were measured by enzyme-linked immunosorbent assay (ELISA). The fertility was observed by giving treated mice 8 weeks for breeding.

RESULTS

We found that primordial follicle counts were increased in the KTC group compared to the Model group. The phosphorylation of PI3K, AKT, mTOR, 4E-BP1 and S6K in the KTC group significantly reduced compared to Model group. Serum FSH and LH levels in the KTC group were decreased compared to the Model group, while, serum E2 and AMH levels in the KTC group were increased compared with the Model group. The litter size in the KTC group was improved compared to Model group.

CONCLUSIONS

The KTC showed protective potentials of ovarian reserve and fertility to attenuate premature ovarian failure, which was relatively associated with activation of the PI3K/AKT/mTOR signaling pathway.

Kuntai Capsule plus Hormone Therapy vs. Hormone Therapy Alone in Patients with Premature Ovarian Failure: A Systematic Review and Meta-Analysis

The aim of this study was to evaluate the efficacy and safety of Kuntai capsules (KTC) plus hormone therapy (HT) compared to HT alone for the treatment of premature ovarian failure (POF). Databases including PubMed, MEDLINE, Web of Science, China National Knowledge Infrastructure (CNKI), the Chinese BioMedical database (CBM), and the Wanfang database were searched up to October 2018 for randomized controlled trials (RCTs). After screening the studies, extracting the data, and assessing the study quality, Cochrane RevMan 5.3 software was used to conduct a meta-analysis. Twelve RCTs involving 1178 patients were included. Regarding the therapeutic effects, total effective treatment rate was higher for the KTC+HT groups compared to the HT-only groups. Furthermore, compared with HT, KTC+HR effectively altered endocrine indexes involving serum levels of luteinizing hormone (weighted mean difference [WMD]=-3.47, 95% CI [5.68, -1.26], P=0.002]), follicle-stimulating hormone [WMD=-8.15, 95% CI [-10.44, -5.86], P<0.00001], estrogen [WMD=17.21, 95% CI [10.16, 24.26], P<0.00001], and anti-Müllerian hormone [WMD=1.07, 95% CI [0.78, 1.36], P<0.00001]; blood lipid indexes involving serum levels of triglyceride (WMD=-0.55, 95% CI [-0.76, -0.43], P<0.00001), total cholesterol (WMD=-0.63, 95% CI [-0.74, -0.52], P<0.00001), and low-density lipoprotein cholesterol (WMD=-0.62, 95% CI [-0.75, -0.49], P<0.00001); and B-ultrasound results involving ovarian resistance index (WMD=-0.20, 95% CI [-0.35, -0.04], P=0.01), perfusion index (WMD=-0.41, 95% CI [-0.57, -0.24], P<0.00001), peak systolic velocity (WMD=2.43, 95% CI [1.52, 3.34], P<0.00001), antral follicle count (WMD=1.20, 95% CI [0.41, 2.00], P=0.003), and mean ovarian diameter in the plane containing the longest axis of the ovary (WMD=4.34, 95% CI [2.94, 5.74], P<0.00001). There were no serious adverse events in either group. There is evidence that KTC+HT is more effective and safer than HT alone for treating POF. However, the trials had low methodological quality and small samples, so further standardized research is required.

Electro-acupuncture attenuates the mice premature ovarian failure via mediating PI3K/AKT/mTOR pathway

AIMS

Electro-acupuncture (EA) is frequently recommended as a complementary therapy for premature ovarian failure (POF) in the clinical. However, little information exists about its potential treatment mechanisms. The study was designed to observe the effect of EA to ovarian function and fertility in POF mice model, and investigated its potential mechanisms on PI3K/AKT/mTOR signaling pathway.

MATERIALS AND METHODS

Forty-five female C57/BL6 mice were divided into the Control, the Model and the EA group. The ovaries morphology of mice was observed by hematoxylin and eosin (HE) staining, and all follicles were counted under microscope. The protein expression of PI3K, phospho-PI3K, AKT, phospho-AKT, mTOR, phospho-mTOR, S6, phospho-S6, 4E-BP1 and phospho-4E-BP1 were detected by western blotting. The data was presented as the ratio of phosphorylation protein to total protein. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E₂) and anti-Mullerian hormone (AMH) levels were measured by enzyme-linked immunosorbent assay (ELISA). The fertility was observed by giving treated mice 8 weeks for breeding.

KEY FINDINGS

We found that primordial follicle counts were increased in EA group compared to Model group. The phosphorylation of PI3K, AKT, mTOR, 4E-BP1 and S6K in EA group significantly reduced compared to Model group. Serum FSH and LH levels in EA group were decreased compared to Model group, while, serum E₂ and AMH levels in EA group were increased compared with Model group. The litter size in EA group was improved compared to Model group.

SIGNIFICANCE

The effects of EA on the PI3K/AKT/mTOR signaling pathway may represent one of the mechanisms involved in attenuating the mice POF.

[Low-intensity pulsed ultrasound promotes repair of cyclophosphamide?induced ovarian injury in rats]

OBJECTIVE

To study the effects of low?intensity pulsed ultrasound (LIPUS) in promoting repair of cyclophosphamide (CTX)?induced ovarian injury in female rats.

METHODS

Fifty female SD rats were subjected to intraperitoneal injection of cyclophosphamide at 30 mg/kg for 5 consecutive days to induce premature ovarian failure. Successful modeling was achieved in 43 rats, which were then randomized into model group (21 rats) and treatment group (22 rats), with another 13 rats without any injections serving as the normal control group. The rats in the treatment group received low?intensity pulsed ultrasound treatment, and those in the other two groups received no interventions. The estrous cycle of the rats was monitored during the experiment, and all the rats were sacrificed 7 days after the treatment for analysis of serum estradiol (E₂), follicle stimulating hormone (FSH), anti?Mullerian hormone (AMH), morphological changes of the ovary and the number of follicles.

RESULTS

Compared with those in the normal control group, the rats in the model group showed disorders in the estrous cycle, reduced number of follicles at all levels, significantly decreased serum E₂ and AMH, and increased serum FSH following CTX injection (P=0.01). Ultrasound treatment obviously promoted the recovery of estrous cycle, significantly increased the number of follicles and serum E₂ (P=0.01), and decreased FSH (P=0.01) in the rats with CTX?induced ovarian injury, but AMH showed no significant changes after ultrasound treatment (P=0.50).

CONCLUSION

Low?intensity pulsed ultrasound can promote the repair of the CTX?induced ovarian injury in SD rats.