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Perelli F, Fusi G, Lonati L, Gargano T, Maffi M, Avanzini S, Palo F, Blanco Verdú MD, Del Cañizo López A, Garrido Colino C, Perucca G, Mattioli G, Gennari F, Lima M, Guanà R. Laparoscopic ovarian tissue collection for fertility preservation in children with malignancies: a multicentric experience. Front Surg 2024; 11:1352698. [PMID: 38322410 PMCID: PMC10844397 DOI: 10.3389/fsurg.2024.1352698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
Introduction Long survivors after childhood cancer are increasing thanks to oncological improvements. Their quality of life and fertility-sparing should be considered in the early phases of each oncological pathway. Cryopreservation of ovarian tissue removed before starting gonadotoxic therapies is the only fertility sparing procedure available for prepubertal children affected by cancer and it does not affect the timing of the start of the treatment. Materials and methods The present study shows the surgical and clinical outcomes following laparoscopic ovarian tissue collection (LOTC) for a total of 311 patients aged between 0 and 17 years old from four different European Centers. Results Only two major complications were reported according to the Clavien Dindo classification (0.6%). Discussion LOTC can be considered a safe procedure.
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Affiliation(s)
- Federica Perelli
- Department of Gynecology and Pediatrics, Azienda USL Toscana Centro, Florence, Italy
| | - Giulia Fusi
- Department of Pediatric Surgery, IRCCS Meyer Children’s Hospital, Florence, Italy
| | - Luca Lonati
- Pediatric Surgery Unit, Regina Margherita Children’s Hospital, Turin, Italy
| | - Tommaso Gargano
- Pediatric Surgery Unit, Sant’Orsola Children’s Hospital, Bologna, Italy
| | - Michela Maffi
- Pediatric Surgery Unit, Sant’Orsola Children’s Hospital, Bologna, Italy
| | | | - Federico Palo
- Pediatric Surgery Department, IRCCS G. Gaslini, Genoa, Italy
| | | | | | | | - Giulia Perucca
- Pediatric Radiology Unit, Great Hormond Street Hospital, London, United Kingdom
| | | | - Fabrizio Gennari
- Pediatric Surgery Unit, Regina Margherita Children’s Hospital, Turin, Italy
| | - Mario Lima
- Pediatric Surgery Unit, Sant’Orsola Children’s Hospital, Bologna, Italy
| | - Riccardo Guanà
- Pediatric Surgery Unit, Regina Margherita Children’s Hospital, Turin, Italy
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Jaeger P, Fournier C, Santamaria C, Fraison E, Morel-Journel N, Benchaib M, Salle B, Lornage J, Labrune E. Human ovarian cryopreservation: vitrification versus slow freezing from histology to gene expression. HUM FERTIL 2023; 26:1099-1107. [PMID: 36384420 DOI: 10.1080/14647273.2022.2136540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/17/2022] [Indexed: 11/18/2022]
Abstract
Cryopreservation of ovarian tissue is one of the strategies offered to girls and women needing gonadotoxic treatment to preserve their fertility. The reference method to cryopreserve is slow freezing; vitrification is an alternative method. The aim was to evaluate which of the two is the best method for human ovarian tissue cryopreservation. Each ovary was divided into three groups: (i) fresh; (ii) slow freezing; and (iii) vitrification. An evaluation of the follicular density, quality and the expression six genes (CYP11A, STAR, GDF9, ZP3, CDK2, CDKN1A) were performed. We observed no significant difference in follicular density within these three groups. Slow freezing altered the primordial follicles compared to the fresh tissue (31.8% vs 55.9%, p = 0.046). The expression of genes involved in steroidogenesis varied after cryopreservation compared to the fresh group; CYP11A was under-expressed in slow freezing group (p = 0.01), STAR was under-expressed in the vitrification group (p = 0.01). Regarding the expression of genes involved in cell cycle regulation, CDKN1A was significantly under-expressed in both freezing groups (slow freezing: p = 0.0008; vitrification: p = 0.03). Vitrification had no effect on the histological quality of the follicles at any stage of development compared to fresh tissue. There was no significant difference in gene expression between the two techniques.
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Affiliation(s)
- Pauline Jaeger
- Service de médecine de la reproduction et préservation de la fertilité - CECOS, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
- INSERM U1208, SBRI, Bron, France
| | - Cyrielle Fournier
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
| | | | - Eloise Fraison
- Service de médecine de la reproduction et préservation de la fertilité - CECOS, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
- INSERM U1208, SBRI, Bron, France
| | | | - Mehdi Benchaib
- Service de médecine de la reproduction et préservation de la fertilité - CECOS, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
- INSERM U1208, SBRI, Bron, France
| | - Bruno Salle
- Service de médecine de la reproduction et préservation de la fertilité - CECOS, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
- Université Calude Bernard, Faculté de médecine et de maieutique Lyon Sud, Pierre Bénite, France
| | - Jacqueline Lornage
- Service de médecine de la reproduction et préservation de la fertilité - CECOS, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
- INSERM U1208, SBRI, Bron, France
| | - Elsa Labrune
- Service de médecine de la reproduction et préservation de la fertilité - CECOS, Hospices Civils de Lyon, Bron, France
- Université Claude Bernard Lyon 1, Faculté de médecine Lyon Est, Lyon, France
- INSERM U1208, SBRI, Bron, France
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Gu R, Ge N, Huang B, Fu J, Zhang Y, Wang N, Xu Y, Li L, Peng X, Zou Y, Sun Y, Sun X. Impacts of vitrification on the transcriptome of human ovarian tissue in patients with gynecological cancer. Front Genet 2023; 14:1114650. [PMID: 37007967 PMCID: PMC10063885 DOI: 10.3389/fgene.2023.1114650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/24/2023] [Indexed: 03/19/2023] Open
Abstract
Objective: This study investigated the effects of a vitrification/warming procedure on the mRNA transcriptome of human ovarian tissues.Design: Human ovarian tissues were collected and processed through vitrification (T-group) and then subjected to RNA sequencing (RNA-seq) analysis, HE, TdT-mediated dUTP nick-end labeling (TUNEL), and real-time quantitative PCR, and the results were compared to those of the fresh group (CK).Results: A total of 12 patients, aged 15–36 years old, with a mean anti-Müllerian hormone level of 4.57 ± 3.31 ng/mL were enrolled in this study. According to the HE and TUNEL results, vitrification effectively preserved human ovarian tissue. A total of 452 significantly dysregulated genes (|log2FoldChange| > 1 and p < 0.05) were identified between the CK and T groups. Among these, 329 were upregulated and 123 were downregulated. A total of 372 genes were highly enriched for 43 pathways (p < 0.05), which were mainly related to systemic lupus erythematous, cytokine–cytokine receptor interaction, the TNF signaling pathway, and the MAPK signaling pathway. IL10, AQP7, CCL2, FSTL3, and IRF7 were significantly upregulated (p < 0.01), while IL1RN, FCGBP, VEGFA, ACTA2, and ASPN were significantly downregulated in the T-group (p < 0.05) compared to the CK group, which agreed with the results of the RNA-seq analysis.Conclusion: These results showed (for the first time to the authors’ knowledge) that vitrification can induce changes in mRNA expression in human ovarian tissues. Further molecular studies on human ovarian tissues are required to determine whether altered gene expression could result in any downstream consequences.
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Affiliation(s)
- Ruihuan Gu
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Naidong Ge
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Bin Huang
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jing Fu
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Female Fertility Preservation, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ningyi Wang
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yan Xu
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Lu Li
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiandong Peng
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yaoyu Zou
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yijuan Sun
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- *Correspondence: Yijuan Sun, ; Xiaoxi Sun,
| | - Xiaoxi Sun
- Department of Shanghai Ji’ai Genetics & IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
- *Correspondence: Yijuan Sun, ; Xiaoxi Sun,
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Development and Survival of Human Ovarian Cells in Chitosan Hydrogel Micro-Bioreactor. Medicina (B Aires) 2022; 58:medicina58111565. [DOI: 10.3390/medicina58111565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background and Objectives: To test the long-term ability of human ovarian cortex cells to develop in unconventional culture conditions. Materials and Methods. Ovarian cortex cells from fetuses aged 23 to 39 weeks gestation were cultured for 90 days in hollow chitosan hydrogel micro-bioreactors and concurrently in traditional wells. Various cell-type counts were considered. Results: With intact follicles as a denominator, the percentage of growing intact follicles at Day 0 varied widely between ovaries (0 to 31.7%). This percentage tended to increase or stay relatively constant in bioreactor as in control cultures; it tended more toward an increase over time in bioreactor vs. control cultures. Modeled percentages showed differences (though not significant) in favor of bioreactor cultures (16.12% difference at D50 but only 0.12% difference at D90). With all follicles present as a denominator, the percentage of growing primary and secondary follicles at D0 varied widely between ovaries (0 to 29.3%). This percentage tended to increase over time in bioreactor cultures but to decrease in control cultures. Modeled percentages showed significant differences in favor of bioreactor cultures (8.9% difference at D50 and 11.1% difference at D90). At D50 and D90, there were only few and sparse apoptotic cells in bioreactor cultures vs. no apoptotic cells in control cultures. Conclusions: Over three months, bioreactor folliculogenesis outperformed slightly traditional culture. This is an interesting perspective for follicle preservation and long-term toxicological studies.
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Anbari F, Khalili MA, Mahaldashtian M, Ahmadi A, Palmerini MG. Fertility preservation strategies for cancerous women: An updated review. Turk J Obstet Gynecol 2022; 19:152-161. [PMID: 35770454 PMCID: PMC9249358 DOI: 10.4274/tjod.galenos.2022.42272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Asadi E, Najafi A, Benson JD. Exogenous Melatonin Ameliorates the Negative Effect of Osmotic Stress in Human and Bovine Ovarian Stromal Cells. Antioxidants (Basel) 2022; 11:antiox11061054. [PMID: 35739950 PMCID: PMC9219940 DOI: 10.3390/antiox11061054] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022] Open
Abstract
Ovarian tissue cryopreservation transplantation (OTCT) is the most flexible option to preserve fertility in women and children with cancer. However, OTCT is associated with follicle loss and an accompanying short lifespan of the grafts. Cryopreservation-induced damage could be due to cryoprotective agent (CPA) toxicity and osmotic shock. Therefore, one way to avoid this damage is to maintain the cell volume within osmotic tolerance limits (OTLs). Here, we aimed to determine, for the first time, the OTLs of ovarian stromal cells (OSCs) and their relationship with reactive oxygen species (ROS) and mitochondrial respiratory chain activity (MRCA) of OSCs. We evaluated the effect of an optimal dose of melatonin on OTLs, viability, MRCA, ROS and total antioxidant capacity (TAC) of both human and bovine OSCs in plated and suspended cells. The OTLs of OSCs were between 200 and 375 mOsm/kg in bovine and between 150 and 500 mOsm/kg in human. Melatonin expands OTLs of OSCs. Furthermore, melatonin significantly reduced ROS and improved TAC, MRCA and viability. Due to the narrow osmotic window of OSCs, it is important to optimize the current protocols of OTCT to maintain enough alive stromal cells, which are necessary for follicle development and graft longevity. The addition of melatonin is a promising strategy for improved cryopreservation media.
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Bahroudi Z, Zarnaghi MR, Izadpanah M, Abedelahi A, Niknafs B, Nasrabadi HT, Seghinsara AM. Review of ovarian tissue cryopreservation techniques for fertility preservation. J Gynecol Obstet Hum Reprod 2021; 51:102290. [PMID: 34906692 DOI: 10.1016/j.jogoh.2021.102290] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022]
Abstract
Ovarian failure and ovarian malfunction are among major fertility problems in women of reproductive age (18-35 years). It is known that various diseases, such as ovarian cancer and premature ovarian failure, besides certain treatments, such as radiotherapy and chemotherapy of other organs, can affect the normal process of folliculogenesis and cause infertility. In recent years, various procedures have been proposed for the treatment of infertility. One of the newest methods is the use of cryopreservation ovarian fragments after cancer treatment. According to some studies, this method yields very satisfactory results. Although ovarian tissue cryopreservation (OTC) is an accepted technique of fertility preservation, the relative efficacy of cryopreservation protocols remains controversial. Considering the controversies about these methods and their results, in this study, we aimed to compare different techniques of ovarian cryopreservation and investigate their advantages and disadvantages. Reviewing the published articles may be possible to identify appropriate strategies and improve infertility treatment in these patients.
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Affiliation(s)
- Zahra Bahroudi
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahsa Rezaei Zarnaghi
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Melika Izadpanah
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Abedelahi
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behrooz Niknafs
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hamid Tayefi Nasrabadi
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abbas Majdi Seghinsara
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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Wang J, Zhang Y, Wu C, Li P, Zhang Z, Xu X, Zhou P, Cao Y. Effects of AavLEA1 Protein on Mouse Ovarian Tissue Cryopreservation by Vitrification. Biopreserv Biobank 2021; 20:168-175. [PMID: 34788107 DOI: 10.1089/bio.2021.0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Conventional ovarian tissue cryopreservation often destroys the structural, functional, and DNA integrity of the ovarian tissue. How to effectively retain the ultrastructure and subsequent function of ovarian tissue during cryopreservation has long been an issue of concern. Late embryogenesis abundant (LEA) proteins are a class of highly hydrophilic proteins and have been reported to protect various cells from water stress. However, whether LEA proteins exert protective effects on ovarian tissue cryopreservation remains unknown. To investigate the benefit of LEA proteins in ovarian tissue cryopreservation, we purified the recombinant AavLEA1 protein, a member of Group 3 LEA proteins, then cryopreserved the mouse ovaries with this protein by vitrification, and obtained the ovarian follicle structure, cellular proliferation, apoptosis, and GAPDH gene expression of postcryopreservation ovaries. We found that recombinant AavLEA1 protein protected the ovarian follicles from cryoinjury, improved the proliferative ability of follicles, decreased the apoptosis, and promoted the GAPDH gene expression. These results indicated that the LEA protein enhanced the antiapoptosis ability of ovarian cells and retained DNA/RNA integrity against cryoinjury during ovarian tissue vitrification. LEA proteins exert beneficial effects on ovarian tissue cryopreservation, and maybe provide a novel cryoprotective agent for ovarian tissue cryopreservation.
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Affiliation(s)
- Jianye Wang
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Yameng Zhang
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Caiyun Wu
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Peng Li
- Medical Affair Department, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhiguo Zhang
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Xiaofeng Xu
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Ping Zhou
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
| | - Yunxia Cao
- Department of Obstetrics and Gynecology, Reproductive Medicine Center, First Affiliated Hospital of Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui Medical University, Hefei, China.,Anhui Provincial Engineering Technology Research Center for Biopreservation and Artificial Organs, Hefei, China
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Effect of Selenium on Expression of Apoptosis-Related Genes in Cryomedia of Mice Ovary after Vitrification. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5389731. [PMID: 33029515 PMCID: PMC7530498 DOI: 10.1155/2020/5389731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/15/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022]
Abstract
Introduction Freezing of ovarian tissue is used for preservation of fertility. The freezing-thawing process is accompanied by oxidative stress and induction of apoptosis. Apoptosis is a complex process that has been studied in animal models. The present study was aimed at investigating the effect of selenium on suppression of apoptosis during vitrification-thawing process of mice ovary via studying expression of apoptosis-related genes, and also, we aimed to design statistical models for the roles of single genes and gene-gene interactions in suppression of apoptosis. Methods A total of 10 right ovary samples from 10 mice were randomly divided into two groups of selenium treatment (at dose 5 μg/ml sodium selenite, through adding to the media) and control group. Vitrification-thawing process was done according to the existed protocols. Real-time PCR was used for gene expression study. The apoptosis gene profile included P53, Bax, Fas, and Bcl-2. General linear model was applied to study single gene associations and gene-gene interactions. Results From the studied genes, P53 showed a significant downregulation in the selenium group in comparison to the control group (∆∆CT = 1.96; P = 0.013; relative expression (RE) = 0.28). Bcl-2 showed a significant upregulation in the selenium group in comparison to the control group (∆∆CT = −2.49; P < 0.001; RE = 3.49). No significant result was found for other genes. According to the multiple models, Bcl-2 showed a protective single gene association (beta = −0.33; P = 0.032), and Fas∗Bcl-2 interaction was significantly positive (beta = 0.19; P = 0.036). Conclusion Addition of selenium to cryomedia of vitrification-thawing process could reduce the apoptosis induced by freezing-thawing stress in mice ovary via downregulation of P53 and upregulation of Bcl-2 at transcription level. Multivariable statistical models should be performed in future researches to study biological systems.
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