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Pencik J, Philippe C, Schlederer M, Atas E, Pecoraro M, Grund-Gröschke S, Li WJ, Tracz A, Heidegger I, Lagger S, Trachtová K, Oberhuber M, Heitzer E, Aksoy O, Neubauer HA, Wingelhofer B, Orlova A, Witzeneder N, Dillinger T, Redl E, Greiner G, D'Andrea D, Östman JR, Tangermann S, Hermanova I, Schäfer G, Sternberg F, Pohl EE, Sternberg C, Varady A, Horvath J, Stoiber D, Malcolm TI, Turner SD, Parkes EE, Hantusch B, Egger G, Rose-John S, Poli V, Jain S, Armstrong CWD, Hoermann G, Goffin V, Aberger F, Moriggl R, Carracedo A, McKinney C, Kennedy RD, Klocker H, Speicher MR, Tang DG, Moazzami AA, Heery DM, Hacker M, Kenner L. STAT3/LKB1 controls metastatic prostate cancer by regulating mTORC1/CREB pathway. Mol Cancer 2023; 22:133. [PMID: 37573301 PMCID: PMC10422794 DOI: 10.1186/s12943-023-01825-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/14/2023] [Indexed: 08/14/2023] Open
Abstract
Prostate cancer (PCa) is a common and fatal type of cancer in men. Metastatic PCa (mPCa) is a major factor contributing to its lethality, although the mechanisms remain poorly understood. PTEN is one of the most frequently deleted genes in mPCa. Here we show a frequent genomic co-deletion of PTEN and STAT3 in liquid biopsies of patients with mPCa. Loss of Stat3 in a Pten-null mouse prostate model leads to a reduction of LKB1/pAMPK with simultaneous activation of mTOR/CREB, resulting in metastatic disease. However, constitutive activation of Stat3 led to high LKB1/pAMPK levels and suppressed mTORC1/CREB pathway, preventing mPCa development. Metformin, one of the most widely prescribed therapeutics against type 2 diabetes, inhibits mTORC1 in liver and requires LKB1 to mediate glucose homeostasis. We find that metformin treatment of STAT3/AR-expressing PCa xenografts resulted in significantly reduced tumor growth accompanied by diminished mTORC1/CREB, AR and PSA levels. PCa xenografts with deletion of STAT3/AR nearly completely abrogated mTORC1/CREB inhibition mediated by metformin. Moreover, metformin treatment of PCa patients with high Gleason grade and type 2 diabetes resulted in undetectable mTORC1 levels and upregulated STAT3 expression. Furthermore, PCa patients with high CREB expression have worse clinical outcomes and a significantly increased risk of PCa relapse and metastatic recurrence. In summary, we have shown that STAT3 controls mPCa via LKB1/pAMPK/mTORC1/CREB signaling, which we have identified as a promising novel downstream target for the treatment of lethal mPCa.
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Affiliation(s)
- Jan Pencik
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria.
- Center for Biomarker Research in Medicine, 8010, Graz, Austria.
- Molecular and Cell Biology Laboratory, The Salk Institute for Biological Studies, La Jolla, CA, 92037, USA.
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090, Vienna, Austria.
| | - Cecile Philippe
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090, Vienna, Austria
| | - Michaela Schlederer
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
| | - Emine Atas
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
| | - Matteo Pecoraro
- Institute for Research in Biomedicine, Università Della Svizzera Italiana, 6500, Bellinzona, Switzerland
| | - Sandra Grund-Gröschke
- Department of Biosciences and Medical Biology, Cancer Cluster Salzburg, Paris-Lodron University of Salzburg, 5020, Salzburg, Austria
| | - Wen Jess Li
- Department of Pharmacology & Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
- Experimental Therapeutics Graduate Program, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Amanda Tracz
- Department of Pharmacology & Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
| | - Isabel Heidegger
- Department of Urology, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Sabine Lagger
- Unit for Pathology of Laboratory Animals, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
| | - Karolína Trachtová
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
- Central European Institute of Technology, Masaryk University, 60177, Brno, Czech Republic
- Christian Doppler Laboratory for Applied Metabolomics (CDL-AM), Medical University of Vienna, 1090, Vienna, Austria
| | | | - Ellen Heitzer
- Institute of Human Genetics, Medical University of Graz, 8010, Graz, Austria
| | - Osman Aksoy
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
- Department for Basic and Translational Oncology and Hematology, Division Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, 3500, Krems, Austria
| | - Heidi A Neubauer
- Institute of Animal Breeding and Genetics, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
| | - Bettina Wingelhofer
- Institute of Animal Breeding and Genetics, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
| | - Anna Orlova
- Institute of Animal Breeding and Genetics, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
| | - Nadine Witzeneder
- Department of Laboratory Medicine, Medical University of Vienna, 1090, Vienna, Austria
| | - Thomas Dillinger
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
| | - Elisa Redl
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
| | - Georg Greiner
- Department of Laboratory Medicine, Medical University of Vienna, 1090, Vienna, Austria
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, 1090, Vienna, Austria
| | - Johnny R Östman
- Department of Molecular Sciences, Swedish University of Agricultural Sciences, 75007, Uppsala, Sweden
| | - Simone Tangermann
- Unit for Pathology of Laboratory Animals, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
| | - Ivana Hermanova
- Center for Cooperative Research in Biosciences, Basque Research and Technology Alliance (BRTA), 20850, Derio, Spain
| | - Georg Schäfer
- Department of Pathology, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Felix Sternberg
- Institute of Physiology, Pathophysiology and Biophysics, University of Veterinary Medicine, 1210, Vienna, Austria
| | - Elena E Pohl
- Institute of Physiology, Pathophysiology and Biophysics, University of Veterinary Medicine, 1210, Vienna, Austria
| | - Christina Sternberg
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
- Unit for Pathology of Laboratory Animals, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
- Biochemical Institute, University of Kiel, 24098, Kiel, Germany
| | - Adam Varady
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
| | - Jaqueline Horvath
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, 1090, Vienna, Austria
| | - Dagmar Stoiber
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, 1090, Vienna, Austria
- Division Pharmacology, Department of Pharmacology, Physiology and Microbiology, Karl Landsteiner University of Health Sciences, 3500, Krems, Austria
| | - Tim I Malcolm
- Department of Pathology, University of Cambridge, Cambridge, CB20QQ, UK
| | - Suzanne D Turner
- Department of Pathology, University of Cambridge, Cambridge, CB20QQ, UK
- Institute of Medical Genetics and Genomics, Faculty of Medicine, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Eileen E Parkes
- Department of Oncology, University of Oxford, Oxford, OX37DQ, UK
| | - Brigitte Hantusch
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
| | - Gerda Egger
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria
- Ludwig Boltzmann Institute Applied Diagnostics, 1090, Vienna, Austria
- Comprehensive Cancer Center, Medical University of Vienna, 1090, Vienna, Austria
| | | | - Valeria Poli
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Turin, 10126, Turin, Italy
| | - Suneil Jain
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT71NN, UK
| | - Chris W D Armstrong
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT71NN, UK
| | | | - Vincent Goffin
- Université Paris Cité, INSERM UMR-S1151, CNRS UMR-S8253, Institut Necker Enfants Malades, 75015, Paris, France
| | - Fritz Aberger
- Department of Biosciences and Medical Biology, Cancer Cluster Salzburg, Paris-Lodron University of Salzburg, 5020, Salzburg, Austria
| | - Richard Moriggl
- Institute of Animal Breeding and Genetics, University of Veterinary Medicine Vienna, 1210, Vienna, Austria
| | - Arkaitz Carracedo
- Center for Cooperative Research in Biosciences, Basque Research and Technology Alliance (BRTA), 20850, Derio, Spain
| | - Cathal McKinney
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT71NN, UK
- Almac Diagnostics, Craigavon, BT63 5QD, UK
| | - Richard D Kennedy
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, BT71NN, UK
- Almac Diagnostics, Craigavon, BT63 5QD, UK
| | - Helmut Klocker
- Department of Urology, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Michael R Speicher
- Institute of Human Genetics, Medical University of Graz, 8010, Graz, Austria
| | - Dean G Tang
- Department of Pharmacology & Therapeutics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
- Experimental Therapeutics Graduate Program, Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Ali A Moazzami
- Department of Molecular Sciences, Swedish University of Agricultural Sciences, 75007, Uppsala, Sweden
| | - David M Heery
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090, Vienna, Austria
| | - Lukas Kenner
- Department of Pathology, Medical University of Vienna, 1090, Vienna, Austria.
- Center for Biomarker Research in Medicine, 8010, Graz, Austria.
- Unit for Pathology of Laboratory Animals, University of Veterinary Medicine Vienna, 1210, Vienna, Austria.
- Christian Doppler Laboratory for Applied Metabolomics (CDL-AM), Medical University of Vienna, 1090, Vienna, Austria.
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Zhang YY, Yang W, Zhang Y, Hu Z, Chen Y, Ma Y, Yang A, Shi Z, Zhou H, Ren P, Shi L, Jin J, Rong Y, Tong X, Zhang YL, Zhang S. HucMSC-EVs Facilitate In Vitro Development of Maternally Aged Preantral Follicles and Oocytes. Stem Cell Rev Rep 2023:10.1007/s12015-022-10495-w. [PMID: 36862330 PMCID: PMC10366269 DOI: 10.1007/s12015-022-10495-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 03/03/2023]
Abstract
Follicle developmental capacity and oocyte quality decline with advanced maternal age. Extracellular vesicles from human umbilical cord mesenchymal stem cells (HucMSC-EVs) act as a potential therapeutic product in the treatment of age-related ovarian dysfunction. In vitro culture (IVC) of preantral follicles is a useful method for understanding the mechanism of follicle development and is a promising means for improving female fertility. However, whether HucMSC-EVs have beneficial effects on aged follicle development during IVC has not yet been reported. Our research demonstrated that follicular development with single-addition withdrawal of HucMSC-EVs was better than that with continuous treatment with HucMSC-EVs. HucMSC-EVs facilitated the survival and growth of follicles, promoted the proliferation of granulosa cells (GCs), and improved the steroid hormone secretion of GCs during IVC of aged follicles. Both GCs and oocytes could uptake HucMSC-EVs. Moreover, we observed elevated cellular transcription in GCs and oocytes after treatment with HucMSC-EVs. The RNA sequencing (RNA-seq) results further validated that the differentially expressed genes are related to the promotion of GC proliferation, cell communication, and oocyte spindle organization. Additionally, the aged oocytes displayed a higher maturation rate, presented less aberrant spindle morphology, and expressed a higher level of the antioxidant protein Sirtuin 1 (SIRT1) after treatment with HucMSC-EVs. Our findings suggested that HucMSC-EVs can improve the growth and quality of aged follicles and oocytes in vitro through the regulation of gene transcription, which provides evidence for HucMSC-EVs as potential therapeutic reagents to restore female fertility with advanced age.
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Affiliation(s)
- Ying-Yi Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Weijie Yang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Yi Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Zhanhong Hu
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Yingyan Chen
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Yerong Ma
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Anran Yang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Zhan Shi
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Hanjing Zhou
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Peipei Ren
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Libing Shi
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Jiamin Jin
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Yan Rong
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Xiaomei Tong
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Yin-Li Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China. .,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China.
| | - Songying Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China. .,Department of Obstetrics and Gynecology, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China.
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3
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Fiorentino G, Cimadomo D, Innocenti F, Soscia D, Vaiarelli A, Ubaldi FM, Gennarelli G, Garagna S, Rienzi L, Zuccotti M. Biomechanical forces and signals operating in the ovary during folliculogenesis and their dysregulation: implications for fertility. Hum Reprod Update 2023; 29:1-23. [PMID: 35856663 DOI: 10.1093/humupd/dmac031] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Folliculogenesis occurs in the highly dynamic environment of the ovary. Follicle cyclic recruitment, neo-angiogenesis, spatial displacement, follicle atresia and ovulation stand out as major events resulting from the interplay between mechanical forces and molecular signals. Morphological and functional changes to the growing follicle and to the surrounding tissue are required to produce oocytes capable of supporting preimplantation development to the blastocyst stage. OBJECTIVE AND RATIONALE This review will summarize the ovarian morphological and functional context that contributes to follicle recruitment, growth and ovulation, as well as to the acquisition of oocyte developmental competence. We will describe the changes occurring during folliculogenesis to the ovarian extracellular matrix (ECM) and to the vasculature, their influence on the mechanical properties of the ovarian tissue, and, in turn, their influence on the regulation of signal transduction. Also, we will outline how their dysregulation might be associated with pathologies such as polycystic ovary syndrome (PCOS), endometriosis or premature ovarian insufficiency (POI). Finally, for each of these three pathologies, we will highlight therapeutic strategies attempting to correct the altered biomechanical context in order to restore fertility. SEARCH METHODS For each area discussed, a systematic bibliographical search was performed, without temporal limits, using PubMed Central, Web of Science and Scopus search engines employing the keywords extracellular matrix, mechanobiology, biomechanics, vasculature, angiogenesis or signalling pathway in combination with: ovary, oogenesis, oocyte, folliculogenesis, ovarian follicle, theca, granulosa, cumulus, follicular fluid, corpus luteum, meiosis, oocyte developmental competence, preimplantation, polycystic ovary syndrome, premature ovarian insufficiency or endometriosis. OUTCOMES Through search engines queries, we yielded a total of 37 368 papers that were further selected based on our focus on mammals and, specifically, on rodents, bovine, equine, ovine, primates and human, and also were trimmed around each specific topic of the review. After the elimination of duplicates, this selection process resulted in 628 papers, of which 287 were cited in the manuscript. Among these, 89.2% were published in the past 22 years, while the remaining 8.0%, 2.4% or 0.3% were published during the 1990s, 1980s or before, respectively. During folliculogenesis, changes occur to the ovarian ECM composition and organization that, together with vasculature modelling around the growing follicle, are aimed to sustain its recruitment and growth, and the maturation of the enclosed oocyte. These events define the scenario in which mechanical forces are key to the regulation of cascades of molecular signals. Alterations to this context determine impaired folliculogenesis and decreased oocyte developmental potential, as observed in pathological conditions which are causes of infertility, such as PCOS, endometriosis or POI. WIDER IMPLICATIONS The knowledge of these mechanisms and the rules that govern them lay a sound basis to explain how follicles recruitment and growth are modulated, and stimulate insights to develop, in clinical practice, strategies to improve follicular recruitment and oocyte competence, particularly for pathologies like PCOS, endometriosis and POI.
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Affiliation(s)
- Giulia Fiorentino
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| | | | | | - Daria Soscia
- Clinica Valle Giulia, GeneraLife IVF, Rome, Italy
| | | | | | - Gianluca Gennarelli
- Obstetrics and Gynecology, Physiopathology of Reproduction and IVF Unit, Department of Surgical Sciences, Sant'Anna Hospital, University of Torino, Turin, Italy.,Livet, GeneraLife IVF, Turin, Italy
| | - Silvia Garagna
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
| | - Laura Rienzi
- Clinica Valle Giulia, GeneraLife IVF, Rome, Italy.,Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Urbino, Italy
| | - Maurizio Zuccotti
- Laboratory of Developmental Biology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.,Center for Health Technologies, University of Pavia, Pavia, Italy
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Zhang T, He M, Zhang J, Tong Y, Chen T, Wang C, Pan W, Xiao Z. Mechanisms of primordial follicle activation and new pregnancy opportunity for premature ovarian failure patients. Front Physiol 2023; 14:1113684. [PMID: 36926197 PMCID: PMC10011087 DOI: 10.3389/fphys.2023.1113684] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/20/2023] [Indexed: 03/08/2023] Open
Abstract
Primordial follicles are the starting point of follicular development and the basic functional unit of female reproduction. Primordial follicles are formed around birth, and most of the primordial follicles then enter a dormant state. Since primordial follicles are limited in number and can't be renewed, dormant primordial follicles cannot be reversed once they enter the growing state. Thus, the orderly occurrence of primordial follicles selective activation directly affects the rate of follicle consumption and thus determines the length of female reproductive lifespan. Studies have found that appropriately inhibiting the activation rate of primordial follicles can effectively slow down the rate of follicle consumption, maintain fertility and delay ovarian aging. Based on the known mechanisms of primordial follicle activation, primordial follicle in vitro activation (IVA) technique has been clinically developed. IVA can help patients with premature ovarian failure, middle-aged infertile women, or infertile women due to gynecological surgery treatment to solve infertility problems. The study of the mechanism of selective activation of primordial follicles can contribute to the development of more efficient and safe IVA techniques. In this paper, recent mechanisms of primordial follicle activation and its clinical application are reviewed.
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Affiliation(s)
- Tuo Zhang
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Transformation Engineering Research Center of Chronic Disease Diagnosis and Treatment, Department of Physiology, College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China.,Prenatal Diagnosis Center in Guizhou Province, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China.,Guizhou Provincial Key Laboratory of Pathogenesis and Drug Research on Common Chronic Diseases, Department of Pathophysiology, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, Guizhou, China.,Guizhou Institute of Precision Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Meina He
- College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China.,Guizhou Institute of Precision Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jingjing Zhang
- Transformation Engineering Research Center of Chronic Disease Diagnosis and Treatment, Department of Physiology, College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China
| | - Yuntong Tong
- Transformation Engineering Research Center of Chronic Disease Diagnosis and Treatment, Department of Physiology, College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China
| | - Tengxiang Chen
- Transformation Engineering Research Center of Chronic Disease Diagnosis and Treatment, Department of Physiology, College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China.,College of Basic Medicine, Guizhou Medical University, Guiyang, Guizhou, China.,Guizhou Provincial Key Laboratory of Pathogenesis and Drug Research on Common Chronic Diseases, Department of Pathophysiology, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, Guizhou, China.,Guizhou Institute of Precision Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Chao Wang
- State Key Laboratory of Agrobiotechnology, College of Biological Sciences, China Agricultural University, Beijing, China
| | - Wei Pan
- Prenatal Diagnosis Center in Guizhou Province, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Ziwen Xiao
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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5
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Intraovarian condensed platelet cytokines for infertility and menopause-Mirage or miracle? Biochimie 2023; 204:41-47. [PMID: 36075561 DOI: 10.1016/j.biochi.2022.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 01/12/2023]
Abstract
On a therapeutic landscape unchanged since the 1980's, oocyte donation with IVF still stands as the solitary medical answer to diminished reserve and premature ovarian insufficiency. In 2016, intraovarian platelet-rich plasma (PRP) crossed the horizon as a hopeful reply to these intertwined problems. The once remote mirage of platelet cytokine effects on gene regulation or telomere stabilization has been brought into sharper focus, with current work clarifying how PRP corrects oxidative stress, rectifies tissue hypoxia, downregulates apoptosis, and enhances cellular metabolism. Not yet ready for routine use, this innovative treatment has already offered at least one point of early consensus: How intraovarian PRP results should be classified-Patients are either responders or non-responders. From this it is intriguing that no published PRP protocol has ever reported a supranormal ovarian rebound or hyperstimulation effect. This might be explained by baseline age-related ovarian conditions prevalent among poor responders, but since dysregulated or malignant transformations are also missing in other tissue contexts following autologous PRP treatment, the contribution of some platelet product which intrinsically delimits regenerative action cannot be discounted. Here we summarize results with recent experimental and clinical platelet research, framing those most likely to help advance reproductive endocrinology practice.
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The Effect of Stimulation Protocols (GnRH Agonist vs. Antagonist) on the Activity of mTOR and Hippo Pathways of Ovarian Granulosa Cells and Its Potential Correlation with the Outcomes of In Vitro Fertilization: A Hypothesis. J Clin Med 2022; 11:jcm11206131. [PMID: 36294452 PMCID: PMC9605084 DOI: 10.3390/jcm11206131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/11/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022] Open
Abstract
Controlled ovarian hyperstimulation (COH) is essential for the success of in vitro fertilization (IVF). Evidence showing the comparison of different COH protocols remains predominantly of low certainty and derives from unspecified infertile and highly heterogeneous populations. Thus, personalized approaches to examine the response of patients to the various COH protocols need to be investigated. Data from in vitro and animal studies have identified the mechanistic target of rapamycin (mTOR) and Hippo signaling pathways play a key role in follicular homeostasis and oocyte quality. To be specific, current data indicate the controlled activation of mTOR and the controlled inhibition of the Hippo pathway within the ovarian granulosa cells (GC). Both are reported to lead to a nurturing follicular microenvironment, increase oocyte quality, and potentially improve reproductive outcomes. As intracellular markers, phosphorylated/unphosphorylated levels of the pathways’ main downstream mediators could be included among the candidate “personalized” predictors of patients’ response to COH protocols and final IVF outcomes. Based on these hypotheses, we make a preliminary attempt to investigate their validity: We propose a prospective cohort study to compare the levels of certain phosphorylated/unphosphorylated components of the investigated pathways (mTOR, ribosomal protein S6 kinase beta-1 (p70S6K-1), yes-associated protein-1 (YAP-1), and transcriptional coactivator with PDZ-binding motif (TAZ)) within the follicular fluid-isolated GC between women undergoing gonadotropin-releasing hormone (GnRH) antagonist/“short” protocols and those receiving GnRH agonist/“long 21” protocols. A case-control design comparing these levels between women achieving pregnancy and those who did not is further planned. Additional analyses addressing the population’s expected heterogeneity are planned after the completion of the pilot phase, during which 100 participants undergoing IVF are intended to be recruited. At this stage, these hypotheses are solely based on in vitro/animal data, and thus, similar studies on humans in this respect are necessary for the investigation of their potential validity.
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7
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Li B, Wang W, Huang Y, Han L, Li J, Zheng N, Wu Z, Zhang X, Li X, Deng L, Lin M, Chen X, Zhang M. Lithium treatment promotes the activation of primordial follicles through PI3K/Akt signaling. Biol Reprod 2022; 107:1059-1071. [PMID: 35871551 DOI: 10.1093/biolre/ioac150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/20/2022] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
In mammals, dormant primordial follicles represent the ovarian reserve throughout reproductive life. In vitro activation of dormant primordial follicles has been used to treat patients with premature ovarian insufficiency (POI). However, there remains a lack of effective strategies to stimulate follicle activation in vivo. In this study, we used an in vitro ovarian culture system and intraperitoneal injection to study the effect of lithium treatment on primordial follicle activation. Lithium increased the number of growing follicles in cultured mouse ovaries and promoted pre-granulosa cell proliferation. Furthermore, lithium significantly increased the levels of phosphorylated protein kinase B (Akt) and the number of oocytes with forkhead Box O3a (FOXO3a) nuclear export. Inhibition of the phosphatidylinositol 3 kinase (PI3K)/Akt pathway by LY294002 reversed lithium-promoted mouse primordial follicle activation. These results suggest that lithium promotes mouse primordial follicle activation by the PI3K/Akt signaling. Lithium also promoted primordial follicle activation and increased the levels of p-Akt in mouse ovaries in vivo and in human ovarian tissue cultured in vitro. Taken together, lithium promotes primordial follicle activation in mice and humans by the PI3K/Akt signaling. Lithium might be a potential oral drug for treating infertility in POI patients with residual dormant primordial follicles.
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Affiliation(s)
- Biao Li
- State Key Laboratory for Agrobiotechnology , College of Biological Sciences, China Agricultural University, Beijing 100193 , China
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Weiyong Wang
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Yingying Huang
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Lincheng Han
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Jia Li
- State Key Laboratory for Agrobiotechnology , College of Biological Sciences, China Agricultural University, Beijing 100193 , China
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Nana Zheng
- State Key Laboratory for Agrobiotechnology , College of Biological Sciences, China Agricultural University, Beijing 100193 , China
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Zhanying Wu
- State Key Laboratory for Agrobiotechnology , College of Biological Sciences, China Agricultural University, Beijing 100193 , China
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Xiaodan Zhang
- State Key Laboratory for Agrobiotechnology , College of Biological Sciences, China Agricultural University, Beijing 100193 , China
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
| | - Xuelan Li
- The Center for Reproductive Medicine , Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Foshan 528300, Guangdong , China
| | - Ling Deng
- The Center for Reproductive Medicine , Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Foshan 528300, Guangdong , China
| | - Min Lin
- The Center for Reproductive Medicine , Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Foshan 528300, Guangdong , China
| | - Xin Chen
- The Center for Reproductive Medicine , Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Foshan 528300, Guangdong , China
| | - Meijia Zhang
- Division of Cell , Developmental and Integrative Biology, School of Medicine, South China University of Technology, Guangzhou 510006 , China
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8
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Kelley DP, Venable K, Destouni A, Billac G, Ebenezer P, Stadler K, Nichols C, Barker S, Francis J. Pharmahuasca and DMT Rescue ROS Production and Differentially Expressed Genes Observed after Predator and Psychosocial Stress: Relevance to Human PTSD. ACS Chem Neurosci 2022; 13:257-274. [PMID: 34990116 DOI: 10.1021/acschemneuro.1c00660] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Post-traumatic stress disorder (PTSD) is associated with cognitive deficits, oxidative stress, and inflammation. Animal models have recapitulated features of PTSD, but no comparative RNA sequencing analysis of differentially expressed genes (DEGs) in the brain between PTSD and animal models of traumatic stress has been carried out. We compared DEGs from the prefrontal cortex (PFC) of an established stress model to DEGs from the dorsolateral PFC (dlPFC) of humans. We observed a significant enrichment of rat DEGs in human PTSD and identified 20 overlapping DEGs, of which 17 (85%) are directionally concordant. N,N-dimethyltryptamine (DMT) is a known indirect antioxidant, anti-inflammatory, and neuroprotective compound with antidepressant and plasticity-facilitating effects. We tested the capacity of DMT, the monoamine oxidase inhibitor (MAOI) harmaline, and "pharmahuasca" (DMT + harmaline) to reduce reactive oxygen species (ROS) production and inflammatory gene expression and to modulate neuroplasticity-related gene expression in the model. We administered DMT (2 mg/kg IP), harmaline (1.5 mg/kg IP), pharmahuasca, or vehicle every other day for 5 days, following a 30 day stress regiment. We measured ROS production in the PFC and hippocampus (HC) by electron paramagnetic resonance spectroscopy and sequenced total mRNA in the PFC. We also performed in vitro assays to measure the affinity and efficacy of DMT and harmaline at 5HT2AR compared to 5-HT. DMT and pharmahuasca reduced ROS production in the PFC and HC, while harmaline had mixed effects. Treatments normalized 9, 12, and 14 overlapping DEGs, and pathway analysis implicated that genes were involved in ROS production, inflammation, growth factor signaling, neurotransmission, and neuroplasticity.
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Affiliation(s)
- D. Parker Kelley
- Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana 70803, United States
| | - Katy Venable
- Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana 70803, United States
| | - Aspasia Destouni
- Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana 70803, United States
| | - Gerald Billac
- Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, United States
| | - Philip Ebenezer
- Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana 70803, United States
| | - Krisztian Stadler
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808, United States
| | - Charles Nichols
- Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, United States
| | - Steven Barker
- Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana 70803, United States
| | - Joseph Francis
- Comparative Biomedical Sciences, Louisiana State University School of Veterinary Medicine, Baton Rouge, Louisiana 70803, United States
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9
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In focus in HCB. Histochem Cell Biol 2021; 154:247-253. [PMID: 32935148 DOI: 10.1007/s00418-020-01911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Li CJ, Lin LT, Tsai HW, Chern CU, Wen ZH, Wang PH, Tsui KH. The Molecular Regulation in the Pathophysiology in Ovarian Aging. Aging Dis 2021; 12:934-949. [PMID: 34094652 PMCID: PMC8139203 DOI: 10.14336/ad.2020.1113] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/13/2020] [Indexed: 12/23/2022] Open
Abstract
The female reproductive system is of great significance to women’s health. Aging of the female reproductive system occurs approximately 10 years prior to the natural age-associated functional decline of other organ systems. With an increase in life expectancy worldwide, reproductive aging has gradually become a key health issue among women. Therefore, an adequate understanding of the causes and molecular mechanisms of ovarian aging is essential towards the inhibition of age-related diseases and the promotion of health and longevity in women. In general, women begin to experience a decline in ovarian function around the age of 35 years, which is mainly manifested as a decrease in the number of ovarian follicles and the quality of oocytes. Studies have revealed the occurrence of mitochondrial dysfunction, reduced DNA repair, epigenetic changes, and metabolic alterations in the cells within the ovaries as age increases. In the present work, we reviewed the possible factors of aging-induced ovarian insufficiency based on its clinical diagnosis and performed an in-depth investigation of the relevant molecular mechanisms and potential targets to provide novel approaches for the effective improvement of ovarian function in older women.
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Affiliation(s)
- Chia-Jung Li
- 1Department of Obstetrics and Gynaecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,2Institute of BioPharmaceutical sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Li-Te Lin
- 1Department of Obstetrics and Gynaecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,2Institute of BioPharmaceutical sciences, National Sun Yat-sen University, Kaohsiung, Taiwan.,3Department of Obstetrics and Gynaecology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Hsiao-Wen Tsai
- 1Department of Obstetrics and Gynaecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,2Institute of BioPharmaceutical sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chyi-Uei Chern
- 1Department of Obstetrics and Gynaecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Zhi-Hong Wen
- 4Department of Marine Biotechnology and Resources, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Peng-Hui Wang
- 3Department of Obstetrics and Gynaecology, National Yang-Ming University School of Medicine, Taipei, Taiwan.,5Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan.,6Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.,7Female Cancer Foundation, Taipei, Taiwan
| | - Kuan-Hao Tsui
- 1Department of Obstetrics and Gynaecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,2Institute of BioPharmaceutical sciences, National Sun Yat-sen University, Kaohsiung, Taiwan.,3Department of Obstetrics and Gynaecology, National Yang-Ming University School of Medicine, Taipei, Taiwan.,8Department of Pharmacy and Master Program, College of Pharmacy and Health Care, Tajen University, Pingtung County, Taiwan
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11
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Wołodko K, Castillo-Fernandez J, Kelsey G, Galvão A. Revisiting the Impact of Local Leptin Signaling in Folliculogenesis and Oocyte Maturation in Obese Mothers. Int J Mol Sci 2021; 22:4270. [PMID: 33924072 PMCID: PMC8074257 DOI: 10.3390/ijms22084270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 12/28/2022] Open
Abstract
The complex nature of folliculogenesis regulation accounts for its susceptibility to maternal physiological fitness. In obese mothers, progressive expansion of adipose tissue culminates with severe hyperestrogenism and hyperleptinemia with detrimental effects for ovarian performance. Indeed, maternal obesity is associated with the establishment of ovarian leptin resistance. This review summarizes current knowledge on potential effects of impaired leptin signaling throughout folliculogenesis and oocyte developmental competence in mice and women.
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Affiliation(s)
- Karolina Wołodko
- Department of Reproductive Immunology and Pathology, Institute of Animal Reproduction and Food Research of PAS, Tuwima 10, 10-748 Olsztyn, Poland;
| | | | - Gavin Kelsey
- Epigenetics Programme, Babraham Institute, Cambridge CB22 3AT, UK; (J.C.-F.); (G.K.)
- Centre for Trophoblast Research, University of Cambridge, Cambridge CB2 3EG, UK
| | - António Galvão
- Department of Reproductive Immunology and Pathology, Institute of Animal Reproduction and Food Research of PAS, Tuwima 10, 10-748 Olsztyn, Poland;
- Epigenetics Programme, Babraham Institute, Cambridge CB22 3AT, UK; (J.C.-F.); (G.K.)
- Centre for Trophoblast Research, University of Cambridge, Cambridge CB2 3EG, UK
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12
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Zhang Y, Zhou X, Zhu Y, Wang H, Xu J, Su Y. Current mechanisms of primordial follicle activation and new strategies for fertility preservation. Mol Hum Reprod 2021; 27:6128515. [PMID: 33538812 DOI: 10.1093/molehr/gaab005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/12/2021] [Indexed: 12/12/2022] Open
Abstract
Premature ovarian insufficiency (POI) is characterized by symptoms caused by ovarian dysfunction in patients aged <40 years. It is associated with a shortened reproductive lifespan. The only effective treatment for patients who are eager to become pregnant is IVF/Embryo Transfer (ET) using oocytes donated by young women. However, the use of the technique is constrained by the limited supply of oocytes and ethical issues. Some patients with POI still have some residual follicles in the ovarian cortex, which are not regulated by gonadotropin. These follicles are dormant. Therefore, activating dormant primordial follicles (PFs) to obtain high-quality oocytes for assisted reproductive technology may bring new hope for patients with POI. Therefore, this study aimed to explore the factors related to PF activation, such as the intercellular signaling network, the internal microenvironment of the ovary and the environment of the organism. In addition, we discussed new strategies for fertility preservation, such as in vitro activation and stem cell transplantation.
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Affiliation(s)
- Yan Zhang
- Department of Gynecology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing 210004, China
| | - Xiaomei Zhou
- Department of Gynecology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing 210004, China
| | - Ye Zhu
- Department of Gynecology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing 210004, China
| | - Hanbin Wang
- Department of Gynecology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing 210004, China
| | - Juan Xu
- Department of Gynecology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing 210004, China
| | - Yiping Su
- Department of Gynecology, Women's Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital), Nanjing 210004, China
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