Treatment Progress in Diminished Ovarian Reserve: Western and Chinese Medicine / 中国结合医学杂志

Diminished ovarian reserve (DOR), generally defined as a decreased number or quality of oocytes, has a significant impact on quality of life and fertility in women. In recent years, the incidence of DOR has been increasing and the ages of patients are younger. The search for an effective DOR treatment has emerged as one of the preeminent research topics in reproductive health. An effective DOR therapy would improve ovarian function, fertility, and quality of life in patients. In this review we evaluated DOR treatment progress both in Western medicine and Chinese medicine, and elucidated the characteristics of each treatment.

Zuogui Pills and Yougui Pills in differential treatment of diminished ovarian reserve based on metabolomics / 中国中药杂志

Based on the metabolomics, this paper systematically analyzed the metabolic substance basis of Zuogui Pills and Yougui Pills in syndrome differentiation and treatment of diminished ovarian reserve(DOR), so as to provide a scientific basis for the traditional Chinese medicine(TCM) syndrome differentiation and treatment of DOR. Patients with DOR of kidney-Yin deficiency syndrome were collected from outpatient department of hospitals and treated with Zuogui Pills for 12 weeks. And kidney-Yang deficiency syndrome were treated with Yougui Pills for 12 weeks. Based on the non-targeted metabolomic research techniques, the potential biomarkers of Zuogui Pills and Yougui Pills in the treatment of DOR with kidney-Yin deficiency and kidney-Yang deficiency, respectively, were screened out, and metabolic pathways of biomarkers were analyzed. The pregnancy rate, basic serum hormone levels [basal follicle-stimulating hormone(bFSH), basal-luteinizing hormone(bLH), basal-estradiol(bE_2), and anti-Müllerian hormone(AMH)], TCM syndrome type score, and Kupperman score were recorded and statistically analyzed after treatment. The results showed that 23 patients with DOR of kidney-Yin deficiency syndrome and 25 patients of kidney-Yang deficiency syndrome were collected. Twenty-six differential metabolites, including L-carnitine, acetyl-CoA, coenzyme A, and coenzyme Q_(10)(CoQ10), were mapped to 12 metabolic pathways in patients with kidney-Yin deficiency treated with Zuogui Pills. Twenty-two differential metabolites, such as adipoyl-CoA, L-lysine, lysine arginine, and α-tocopherol, were mapped to 11 metabolic pathways in patients with kidney-Yang deficiency. After treatment, bFSH and bLH of patients with DOR were significantly lower than those before treatment(P<0.05). Although the comparison of bE_2 and AMH had no significant differences, there was a improvement trend. The TCM syndrome type score and Kupperman score of patients with DOR after TCM treatment were significantly lower than those before treatment(P<0.05).

Mechanism of Liuwei Dihuang Pills in treatment of mice with diminished ovarian reserve based on proteomics / 中国中药杂志

This study aims to investigate the efficacy and possible mechanism of Liuwei Dihuang Pills in the treatment of diminished ovarian reserve(DOR) by using proteomic techniques. Firstly, cyclophosphamide(60 mg·kg~(-1)) combined with busulfan(6 mg·kg~(-1)) was injected intraperitoneally to establish the mouse model of DOR. After drug injection, the mice were continuously observed and the success of modeling was evaluated by the disturbance of the estrous cycle. After successful modeling, the mice were administrated with the suspension of Liuwei Dihuang Pills by gavage for 28 days. At the end of the gavage, four female mice were selected and caged together with males at a ratio of 2∶1 for the determination of the pregnancy rate. Blood and ovary samples were collected from the remaining mice on the next day after the end of gavage. Hematoxylin-eosin(HE) staining and transmission electron microscopy(TEM) were then employed to observe the morphological and ultrastructural changes in the ovaries. The serum levels of hormones and oxidation indicators were measured by enzyme-linked immunosorbent assay. Quantitative proteomics techniques were used to compare the ovarian protein expression before and after modeling and before and after the intervention with Liuwei Dihuang Pills. The results showed that Liuwei Dihuang Pills regulated the estrous cycle of DOR mice, elevated the serum levels of hormones and anti-oxidation indicators, promoted follicle development, protected the mitochondrial morphology of ovarian granulosa cells, and increased the litter size and survival of DOR mice. Furthermore, Liuwei Dihuang Pills negatively regulated the expression of 12 differentially expressed proteins associated with DOR, which were mainly involved in lipid catabolism, inflammatory response, immune regulation, and coenzyme biosynthesis. These differentially expressed proteins were significantly enriched in sphingolipid metabolism, arachidonic acid metabolism, ribosomes, ferroptosis, and cGMP-PKG signaling pathway. In summary, the occurrence of DOR and the treatment of DOR with Liuwei Dihuang Pills are associated with multiple biological pathways, mainly including oxidative stress response, inflammatory response, and immune regulation. "Mitochondria-oxidative stress-apoptosis" is the key to the treatment of DOR by Liuwei Dihuang Pills. YY1 and CYP4F3 may be the key upstream targets that trigger mitochondrial dysfunction and ROS accumulation, and the metabolism of arachidonic acid is the main signaling pathway of drug action.

Effects of Zishen Yutai Pills on in vitro Fertilization-Embryo Transfer Outcomes in Patients with Diminished Ovarian Reserve: A Prospective, Open-Labeled, Randomized and Controlled Study / 中国结合医学杂志

OBJECTIVE@#To explore the effects of Zishen Yutai Pills (ZYPs) on the quality of oocytes and embryos, as well as pregnancy outcomes in patients with diminished ovarian reserve (DOR) receiving in vitro fertilization-embryo transfer (IVF-ET). The possible mechanisms, involving the regulation of bone morphogenetic protein 15 (BMP15) and growth differentiation factor 9 (GDF9), were also investigated.@*METHODS@#A total of 120 patients with DOR who underwent their IVF-ET cycle were randomly allocated to 2 groups in a 1:1 ratio. The patients in the treatment group (60 cases) received ZYPs from the mid-luteal phase of the former menstrual cycle by using gonadotropin-releasing hormone (GnRH) antagonist protocol. The patients in the control group (60 cases) received the same protocol but without ZYPs. The primary outcomes were the number of oocytes retrieved and high-quality embryos. Secondary outcomes included other oocyte or embryo indices as well as pregnancy outcomes. Adverse events were assessed by comparison of the incidence of ectopic pregnancy, pregnancy complications, pregnancy loss, and preterm birth. Contents of BMP15 and GDF9 in the follicle fluids (FF) were also quantified with enzyme-linked immunosorbent assay.@*RESULTS@#Compared with the control group, the numbers of oocytes retrieved and high-quality embryos were significantly increased in the ZYPs group (both P<0.05). After treatment with ZYPs, a significant regulation of serum sex hormones was observed, including progesterone and estradiol. Both hormones were up-regulated compared with the control group (P=0.014 and 0.008), respectively. No significant differences were observed with regard to pregnancy outcomes including implantation rates, biochemical pregnancy rates, clinical pregnancy rates, live birth rates, and pregnancy loss rates (all P>0.05). The administration of ZYPs did not increase the incidence of adverse events. The expressions of BMP15 and GDF9 in the ZYPs group were significantly up-regulated compared with the control group (both P<0.05).@*CONCLUSIONS@#ZYPs exhibited beneficial effects in DOR patients undergoing IVF-ET, resulting in increments of oocytes and embryos, and up-regulation of BMP15 and GDF9 expressions in the FF. However, the effects of ZYPs on pregnancy outcomes should be assessed in clinical trials with larger sample sizes (Trial reqistration No. ChiCTR2100048441).

Prevention of Premature Ovulation by Administration of Gonadotropin Releasing Hormone Antagonist the day After Ovulation Triggering in Diminished Ovarian Reserve Patients / Prevenção da ovulação prematura por meio da administração de antagonismo de liberação de gonadotropismo no dia seguinte à ovulação

Abstract Objective The aim of the present retrospective study was to investigate the effectiveness of single-dose gonadotropin releasing hormone (GnRH) antagonist administration, the day after human chorionic gonadotropin (hCG) triggering for final oocyte maturation, on the prevention of premature luteinization in patients with diminished ovarian reserve in in-vitro fertilization (IVF) cycles. The secondary objective of the study was to search the effect of this protocol on pregnancy outcomes. Methods This is a retrospective study including 267 infertile patients who have single antral follicle seen with ultrasonography on the 2nd or 3rd day of the menstrual cycle before starting IVF treatment. We randomized patients into two groups. The case group comprised patients who had single-dose GnRH antagonist injection the day after hCG triggering formed, and the patients who had the standard treatment regime formed the control group. In both groups, the oocytes were collected 36 hours after hCG injection. Results The premature ovulation rate was significantly low in the case group compared with the control group (6.86 versus 20.6% per scheduled cycle) (p=0.022). Also, the oocyte retrieval rate (93.14 versus 67.87% per scheduled cycle) (p=0.013), the oocyte maturity rate (79.42 versus 47.87%) (p=0.041), the fertilization rate (65.68 versus 34.54%) (p=0.018), and the embryo transfer rate per scheduled cycle (44.11 versus 18.78%) (p=0.003) were higher in the GnRH antagonist group than in the control group. Conclusion The administration of GnRH antagonist the day after hCG trigger in IVF treatments of patients with diminished ovarian reserve enabled a significant decrease in the rate of premature ovulation but had no effect on live birth rate.

Resumo Objetivo O objetivo do presente estudo retrospectivo foi investigar a eficácia da administração do antagonista do hormônio liberador da gonadotrofina (GnRH) em dose única no dia seguinte ao desencadeamento da gonadotrofina coriônica humana (hCG) para a maturação final do oócito, na prevenção da luteinização prematura em pacientes com diminuição do ovário reserva em ciclos de fertilização in vitro (FIV). O objetivo secundário do estudo foi pesquisar o efeito deste protocolo nos resultados da gravidez. Métodos Trata-se de um estudo retrospectivo incluindo 267 pacientes inférteis que apresentam um único folículo antral visto por ultrassonografia no 2° ou 3° dia do ciclo menstrual antes de iniciar o tratamento de FIV. Nós randomizamos os pacientes em dois grupos. Os pacientes que receberam injeção de antagonista de GnRH em dose única no dia seguinte ao desencadeamento do hCG formaram o grupo caso, e os pacientes que receberam o regime de tratamento padrão formaram o grupo controle. Em ambos os grupos, os oócitos foram coletados 36 horas após a injeção de hCG. Resultados A taxa de ovulação prematura foi significativamente baixa no grupo caso em comparação com o grupo controle (6,86 versus 20,6% por ciclo programado) (p=0,022). Além disso, a taxa de recuperação de oócitos (93,14 versus 67,87% por ciclo programado) (p=0,013), a taxa de maturidade do oócito (79,42 versus 47,87%) (p=0,041), a taxa de fertilização (65,68 versus 34,54%) (p=0,018) e a taxa de transferência de embriões por ciclo programado (44,11 versus 18,78%) (p=0,003) foram maiores no grupo antagonista de GnRH do que no grupo controle. Conclusão A administração de antagonista de GnRH, no dia seguinte ao desencadeamento de hCG em tratamentos de FIV de pacientes com reserva ovariana diminuída permitiu uma redução significativa na taxa de ovulação precoce,mas não teve efeito na taxa de nascidos vivos.

Effect of Siwutang on Diminished Ovarian Reserve in Rats Based on 16S rRNA Sequencing of Intestinal Flora / 中国实验方剂学杂志

ObjectiveTo study the effect of Siwutang （SWT） on intestinal flora in rats with diminished ovarian reserve （DOR） induced by Tripterygium wilfordii polyglycoside （TWP） based on 16S rRNA sequencing. MethodTwenty 8-week-old female SD rats were randomly assigned into four groups： blank group， model group， SWT high-dose group， and SWT low-dose group. Except the blank group， the other three groups were underwent intragastric administration of TWP tablets at a dose of 50 mg·kg-1 for 14 days. On day 15， the high-dose group was administrated at 3 times of the human dosage （40 g/person/day）， the low-dose group at 1.5 times of the human dosage， and the model group and the blank group with the same volume of normal saline for 18 days. Then， feces were collected for 16S rRNA sequencing. One hour after administration， blood was sampled from abdominal aorta after anesthesia for the measurement of hormone levels by radioimmunoassay， and ovaries were sampled， embedded， sliced， and stained with haematoxylin-eosin （HE） for pathological observation. ResultThe model group had higher level of luteinizing hormone （LH， P<0.05） and lower level of estradiol （E2， P<0.05） than the blank group. The SWT high-dose group and low-dose group had lower LH levels （P<0.05） and higher E2 levels than the model group （P<0.05）. SWT reversed the elevation in follicle-stimulating hormone （FSH） and LH levels and the decline in E2 and progesterone （P） levels caused by TWP to some extent. There were a large number of follicles at different developmental stages in the blank group， while atretic follicles increased significantly in the model group. A large number of mature follicles， secondary follicles， and primary follicles were observed in the high-dose SWT group， and primordial follicles， secondary follicles， and increased corpus luteum in the low-dose SWT group. Compared with that in the blank group and the administration group， the abundance of Verrucomicrobia and Epsilonbacteraeota in the model group significantly reduced. Compared with the blank group， the model group had different intestinal flora in phylum， class， order， family， and genus levels. Specifically， the model group had increased proportions of Firmicutes and Bacteroidetes. After TWP modeling， the abundance of Lachnospiraceae decreased significantly while that of Ruminococcaceae UCG-005 increased significantly. SWT groups， blank group， and model group can be clearly distinguished， and SWT groups had a tendency to approach the blank group. ConclusionSWT may improve the ovarian function of rats with TWP-induced DOR by regulating intestinal flora diversity.

Effects of Bushen Yiqi Huoxue Decoction in Treatment of Patients with Diminished Ovarian Reserve: A Randomized Controlled Trial / 中国结合医学杂志

OBJECTIVE@#To explore the therapeutic effect of Bushen Yiqi Huoxue Decoction BYHD) in patients with diminished ovarian reserve (DOR).@*METHODS@#A total of 180 patients with DOR diagnosed from December 2013 to December 2014 were equally assigned into progynova and duphaston (E+D) group, Zuogui Pill group and BYHD group with 60 cases in each by computerized randomization. Patients received E+D, Zuogui Pill or BYHD for 12 months, respectively. Follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), anti-Müllerian hormone (AMH), antral follicle count (AFC), ovarian volume, endometrial thickness, and the resistance indices (RIs) of ovarian arteries and uterine arteries were observed before and after treatment.@*RESULTS@#Nine women (4 from the E+D group, 3 from the Zuogui Pill group, and 2 from the BYHD group) withdrew from the study. After 6 months, Zuogui Pill and BYHD significantly decreased FSH and LH and increased endometrial thickness and AMH (all P<0.01). BYHD also resulted in E2 elevation (P<0.05), ovary enlargement (P<0.05), AFC increase (P<0.01), and RI of ovarian arteries decrease (P<0.05). After 12 months, further improvements were observed in the Zuogui Pill and BYHD groups (all P<0.01), but BYHD showed better outcomes, with lower FSH, larger ovaries and a thicker endometrium compared with the Zuogui Pill group (all P<0.01). However, E+D only significantly increased endometrial thickness (P<0.01) and no significant improvements were observed in the RI of uterine arteries in the three groups.@*CONCLUSIONS@#BYHD had a favorable therapeutic effect in patients with DOR by rebalancing hormone levels, promoting ovulation, and repairing the thin endometrium. The combination of tonifying Shen (Kidney), benefiting qi and activating blood circulation may be a promising therapeutic strategy for DOR.

Clinical efficacy of Bushen Huoxue Culuan Formula in treatment of infertility caused by diminished ovarian reserve due to kidney deficiency and blood stasis / 中国中药杂志

To study the clinical efficacy and safety of Bushen Huoxue Culuan Formula in treating infertility caused by diminished ovarian reserve(DOR) with kidney deficiency and blood stasis. A total of 100 DOR patients treated at Xiyuan Hospital, Acupuncture Hospital and Clinic of China Academy of Chinese Medical Sciences from 2017 to 2020 in line with the inclusion criteria were selected and randomly divided into experimental group and control group at the ratio of 1∶1. The experimental group was treated with Bushen Huoxue Culuan Formular, while the control group was treated with Climen and Clomiphene for 3 menstrual cycles. The ovulation rate, pregnancy rate, pregnancy success rate, serum hormone levels, and traditional Chinese medicine(TCM) symptom scores were observed in the 2 groups. The total effective rate was 92.00% in the experimental group and 72.00% in the control group, with a statistical difference between the two groups(P<0.01); the experimental group was superior to the control group in reducing FSH level, increasing AMH level, improving TCM symptoms, increasing pregnancy rate and pregnancy success rate, with a significant difference(P<0.05). There was no abnormal safety indicator and adverse reaction. Bushen Huoxue Culuan Formular is effective in treating infertility caused by DOR due to kidney deficiency and blood stasis, with a safety and reliability.

Effect of moxibustion on Nrf2/HO-1 signaling pathway in rats with diminished ovarian reserve / 中国针灸

OBJECTIVE@#To observe the effect of moxibustion on Nrf2/HO-1 signaling pathway in rats with diminished ovarian reserve (DOR), and to explore the protective mechanism of moxibustion on ovarian reserve function.@*METHODS@#Forty SD rats were randomly divided into a blank group, a model group, a moxibustion group and a hormone group, 10 rats in each group. The rats in the model group, moxibustion group and hormone group were treated with intragastric administration of tripterysium glycosides turbid liquid to prepare DOR model. The rats in the blank group were treated with intragastric administration of sodium chloride solution with the same volume, once a day for 14 days. The rats in the hormone group were treated with hormone sequential therapy for 14 days from the day of modeling; the rats in the moxibustion group were treated with moxibustion at bilateral "Shenshu" (BL 23) or "Guanyuan" (CV 4) and "Zhongwan" (CV 12) from the day of modeling, and the two groups acupoints were alternated every other day, 10 min each time, for 14 consecutive days. The estrus cycle was observed every day by vaginal exfoliated cell smear, and the estrus cycle disorder rate in each group was calculated. After the intervention, the HE staining was used to observe the histological morphology of ovaries; ELISA was used to detect the contents of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E@*RESULTS@#Compared with the blank group, the rate of estrus cycle disorder in the model group was increased (@*CONCLUSION@#Moxibustion could reduce the rate of estrus cycle disorder, improve the level of serum sex hormones and antioxidant stress in DOR rats, and the mechanism may be related to the regulation of Nrf2/HO-1 signaling pathway.

Modified Dihuang Decoction improves ovarian reserve in mice by regulating Bcl-2-related mitochondrial apoptosis pathway / 中国中药杂志

The present study investigated the effect of Modified Dihuang Decoction in improving ovarian reserve in mice through the Bcl-2-related mitochondrial apoptosis pathway. Forty-eight adult female BALB/c mice were randomly divided into the following six groups with eight mice in each group: a blank group, a model group, a femoston group(three cycles of treatment with 0.13 mg·kg~(-1) estradiol tablets for 2 days and 1.43 mg·kg~(-1) estradiol and dydrogesterone tablets for 3 days), and high(64.74 g·kg~(-1))-, medium(43.16 g·kg~(-1))-, and low-dose(21.58 g·kg~(-1)) Modified Dihuang Decoction groups. Mice in other groups except the blank group received a single intraperitoneal injection of 12 mg·kg~(-1) cyclophosphamide and 1.2 mg·kg~(-1) busulfan to induce a model of diminished ovarian reserve(DOR), while those in the blank group received an equal volume of normal saline. Mice were treated with corresponding drugs for 15 d from the 36 th day, once per day, and the mice in the blank group and the model group were treated with an equal volume of normal saline. The general condition and oestrous cycle were observed. The serum hormone levels were detected with the enzyme-linked immunosorbent assay(ELISA). The morphological changes of ovaries were observed by HE staining. Western blot was used to detect the protein expression of cysteinyl aspartate specific proteinase-9(caspase-9), cleaved caspase-3, Bcl-2 associated X protein(Bax), Bcl-2, superoxide dismutase-2(SOD-2), and glutathione peroxidase-1(GPx-1). The mRNA expression of Bax and Bcl-2 was detected by real-time fluorescence-based quantitative polymerase chain reaction(real-time PCR). The results showed that compared with the blank group, the model group showed body weight loss, disordered oestrous cycle, elevated serum levels of follicle-stimulating hormone(FSH) and luteinizing hormone(LH), reduced serum levels of estradiol(E_2), anti-mullerian hormone(AMH), and inhibin B(INHB), the declining number of ovarian follicles and granulosa layers, increased number of atretic follicles, up-regulated protein expression of caspase-9, cleaved caspase-3, and Bax and Bax mRNA expression in ovaries, and down-regulated protein expression of Bcl-2, SOD-2 and GPx-1, and Bcl-2 mRNA expression. Compared with the model group, the Modified Dihuang Decoction groups displayed restored body weight and oestrous cycle, decreased serum levels of FSH and LH, elevated serum levels of E_2, AMH, and INHB, increased number of ovarian follicles, thickened granulosa layers, and declining number of atretic follicles. Additionally, the protein expression of caspase-9, cleaved caspase-3, and Bax, and Bax mRNA expression was down-regulated, and the protein expression of Bcl-2, SOD-2, and GPx-1, and Bcl-2 mRNA expression was up-regulated. The results suggest that Modified Dihuang Decoction can regulate endocrine hormone, promote follicle growth and improve ovarian reserve by enhancing ovarian anti-oxidant capacity, inhibiting the Bcl-2-related mitochondrial apoptosis pathway, and further inhibiting cell apoptosis.

Bushen Huoxue Prescription Replenishes Diminished Ovarian Reserve in Rats Through PI3K/Akt/mTOR Signaling Pathway / 中国实验方剂学杂志

Objective:To explore the mechanism of Bushen Huoxue prescription in regulating the related factors in phosphatidylinositol 3-kinase （PI3K）/ protein kinase B （Akt）/ mammalian target of rapamycin （mTOR） pathway and improving ovarian reserve function of rats with diminished ovarian reserve （DOR）. Method:Sixty DOR model rats were duplicated by Ataya method （intraperitoneal injection of cyclophosphamide） and then randomized into the model group， estradiol valerate （0.000 9 g·kg^-1） group， and high- （33 g·kg^-1）， middle- （16.5 g·kg^-1） and low-dose （8.25 g·kg^-1） Bushen Huoxue prescription groups， with 12 rats in each group. Another 12 healthy rats were classified into the blank control group. The rats in each group were given the corresponding drugs by gavage， while those in the blank control group and model group received the same volume of normal saline， once per day， for 14 successive days. After treatment， the ovarian tissue was stained with hematoxylin-eosin （HE） for observing the changes in quantities of primary follicles， mature follicles， and total follicles under a light microscope， followed by the detection of vascular endothelial growth factor （VEGF） expression in the ovarian tissue by immunohistochemistry. The protein expression levels of PI3K， Akt， mTOR， and cysteine-dependent aspartate-directed protease-3 （Caspase-3） in the ovarian tissue were assayed by Western blot， whereas the mRNA expression levels of PI3K， Akt， and mTOR were measured by Real-time polymerase chain reaction （Real-time PCR）. Result:As revealed by comparison with the blank control group， the quantities of mature follicles and total follicles in the ovarian tissue of model group were significantly reduced （<italic>P</italic><0.05， <italic>P</italic><0.01）. The protein expression levels of VEGF and Caspase-3 in the ovarian tissue were increased （<italic>P</italic><0.05）， while the protein and mRNA expression levels of PI3K， Akt， and mTOR were decreased （<italic>P</italic><0.05， <italic>P</italic><0.01）. Compared with the model group， Bushen Huoxue prescription at the high and middle doses elevated the quantities of mature follicles and total follicles to varying degrees （<italic>P</italic><0.05， <italic>P</italic><0.01）， and VEGF increased most significantly in the middle-dose Bushen Huoxue prescription group （<italic>P</italic><0.05）. Caspase-3 in the low-， middle-， and high-dose Bushen Huoxue prescription groups and the western medicine group declined. The protein and mRNA expression levels of PI3K， Akt， and mTOR were up-regulated in the middle- and high-dose Bushen Huoxue prescription groups （<italic>P</italic><0.05， <italic>P</italic><0.01）， and the levels in the middle-dose Bushen Huoxue prescription group were closer to those in the blank control group. Conclusion:Bushen Huoxue prescription effectively improves the ovarian reserve function of rats with DOR and increases the number of follicles possibly by up-regulating VEGF expression in the ovarian tissue， activating the PI3K/Akt/mTOR signaling pathway， and regulating the content of Caspase-3.

Effect of Danggui Shaoyaosan on Diminished Ovarian Reserve in Model Rats： An Exploration Based on TGF-β1/ Smads Signaling Pathway / 中国实验方剂学杂志

Objective:To observe the improving effect of Danggui Shaoyaosan on diminished ovarian reserve （DOR） in rats triggered by Tripterygia wilfordii polyglycoside tablet combined with stress， and to explore the role of transforming growth factor-<italic>β</italic>₁（TGF-<italic>β</italic>₁）/Smads signaling pathway in such improvement. Method:Forty-eight female SD rats with normal sexual cycle were selected and randomly divided into a normal group （<italic>n</italic>=8） and a modeling group （<italic>n</italic>=40）， and the ones in the modeling group were given Tripterygium wilfordii polyglycoside tablets （50 mg·kg^-1） combined with random stress for 15 d. After successful modeling， the rats were randomized into the model group， low-， medium-， and high-dose （3.96， 7.92， 15.84 g·kg^-1） Danggui Shaoyaosan groups， and estradiol valerate group （0.09 mg·kg^-1）， with eight in each group. Under the premise of stress exposure， they were separately gavaged with the normal saline， low-， medium- and high-dose Danggui Shaoyaosan， and estradiol valerate for 15 successive days. The estrous cycle of rats in each group was observed daily. After intervention， the rats were sacrificed and the ovarian visceral index was calculated. The pathological changes in ovarian tissues were observed by hematoxylin eosin （HE） staining. The protein expression levels of TGF-<italic>β</italic>₁ and TGF-<italic>β</italic>₁receptor （TGF-<italic>β</italic>₁R） in the ovarian tissues of rats were measured by immunohistochemistry （IHC）， and the mRNA expression levels of Smad2， Smad3， and Smad7 in the ovarian tissues by real-time polymerase chain reaction （Real-time PCR）. Result:Compared with the normal group， the model group exhibited disordered estrus cycle （<italic>P</italic><0.05）， reduced visceral index （<italic>P</italic><0.01）， and down-regulated TGF-<italic>β</italic>₁ and TGF-<italic>β</italic>₁R protein and Smad2 and Smad3 mRNA expression in the ovarian tissues （<italic>P</italic><0.01）， and up-regulated Smad7 mRNA expression （<italic>P</italic><0.01）. Compared with the model group， Danggui Shaoyaosan at the low， medium， and high doses and estradiol valerate improved the estrus cycle of rats to varying degrees （<italic>P</italic><0.05） and increased the visceral index， with better effects observed in the medium-group and high-dose Danggui Shaoyaosan groups （<italic>P</italic><0.05，<italic>P</italic><0.01）. Besides， the protein expression levels of TGF-<italic>β</italic>₁ and TGF-<italic>β</italic>₁R and the mRNA expression levels of Smad2 and Smad3 in the ovarian tissues were elevated to varying degrees （<italic>P</italic><0.01）， and the Smad7 mRNA expression declined （<italic>P</italic><0.01）. The improvements in TGF-<italic>β</italic>₁ and TGF-<italic>β</italic>₁R protein expression of the medium-dose Danggui Shaoyaosan group and estradiol valerate group were more obvious. Conclusion:Danggui Shaoyaosan significantly improves ovarian reserve in DOR rats， which is closely related to the regulation of TGF-<italic>β</italic>₁/Smads signaling pathway.

"Thirteen acupoints for regulating menstruation and promoting pregnancy" for diminished ovarian reserve: a prospective cohort study / 中国针灸

OBJECTIVE@#To evaluate the clinical effect of acupuncture at "thirteen acupoints for regulating menstruation and promoting pregnancy" on diminished ovarian reserve (DOR) and its influence on ovarian reserve function.@*METHODS@#A total of 32 patients with DOR were treated by acupuncture at "thirteen acupoints for regulating menstruation and promoting pregnancy". Acupoints group 1: Baihui (GV 20), Shenting (GV 24), Benshen (GB 13), Zhongwan (CV 12), Tianshu (ST 25), Guanyuan (CV 4), Zigong (EX-CA 1), Dahe (KI 12), Zusanli (ST 36), Sanyinjiao (SP 6), Taichong (LR 3); acupoints group 2: Baihui (GV 20), Shenshu (BL 23), Ciliao (BL 32). Acupoints group 1 and group 2 were alternately used, and acupoints group 1 was used for the first time. The needles were stayed for 30 min each time, once every 1 or 2 days, 3 times a week, 36 times (3 months) as a course of treatment. The treatment could be continued until the patient was pregnant or the patient given up acupuncture, and the acupuncture was uninterrupted during menstruation. The changes of modified Kupperman scale score, serum sex hormones, anti-müllerian hormones (AMH), ovarian peak systolic velocity (PSV), resistive index (RI) and antral follicle count (AFC) were compared before and after treatment, and the clinical effect and pregnancy rate were observed.@*RESULTS@#The total score of modified Kupperman scale after treatment was lower than that before treatment (<0.05); The total effective rate was 90.6% (29/32) and the pregnancy rate was 15.6% (5/32). After treatment, the levels of follicle stimulating hormone (FSH), FSH/ luteinizing hormone (LH) were lower than before treatment, ovarian PSV was higher than before treatment, RI was lower than before treatment, and AFC was more than before treatment (<0.05).@*CONCLUSION@#Acupuncture at "thirteen acupoints for regulating menstruation and promoting pregnancy" can effectively improve the ovarian reserve function of DOR patients.

Effect of Dingkundan on Sex Hormone and Follicle Count in Mice of Tripterygium Wilfordii Polyglycosides Induced Diminished Ovarian Reserve / 中国实验方剂学杂志

Objective:To establish a mouse model of diminished ovarian reserve （DOR） induced by tripterygium wilfordii polyglycosides （TWP）， and to explore the therapeutic effect of Dingkundan （DKD） on DOR， so as to provide scientific basis for its clinical application. Method:The 60 female Blab/c mice with regular estrous cycle were randomly divided into blank group， model group， low，medium and high-dose DKD group， DKD group and estradiol valerate group， with 10 mice in each group. Except the blank group， the other groups were given 40 mg·kg-1 TWP suspension. Meantime，low，medium and high-dose DKD group were given 1.64，3.28，6.56 g·kg-1 DKD suspension respectively， and estradiol valerate group was given 0.15 mg·kg-1 estradiol valerate suspension by gastric lavage once a day for 30 days. The general condition， body weight， estrous cycle and gonad index of mice were observed， serum follicle-stimulating hormone （FSH）， luteinizing hormone （LH） and estradiol （E2） were determined by radioimmunoassay， ovarian morphology and follicle count were observed by hematoxylin-eosin staining （HE） staining. Result:Compared with the blank group， most of the mice in model group had disordered estrous cycle， uterine and ovarian indexes decreased （P<0.05）， serum FSH increased （P<0.05）， LH was on an upward trajectory， E2 was on a downward trend， and the number of growth follicles and corpus luteum decreased and the number of atresia follicles increased（P<0.05）. Compared with the model group， half of the mice in DKD group resumed regular estrous cycle， however， the estrous cycles of mice in estradiol valerate group were stagnated during estrous period. In medium-dose， high-dose DKD group and estradiol valerate group， the uterine and ovarian indexes of the mice were increased， the serum FSH value decreased （P<0.05） and serum LH was on a downward trend， high-dose DKD group and estradiol valerate group increased the levels of serum E2 （P<0.05）. In DKD group， the number of growth follicles and corpus luteum were increased and the number of atresia follicles were reduced （P<0.05）， with the best effect at medium dosage. And in estradiol valerate group， the number of primitive follicles， sinusoidal follicles and corpus luteum were increased （P<0.05）， but the number of atresia follicles had no difference to the model group. Conclusion:DKD can improve serum sex hormones， promote follicular development and reduce follicular atresia， which can play a therapeutic role in the treatment of DOR.

Clinical observation on herb-partitioned spreading moxibustion at Baliao points plus climen for diminished ovarian reserve / 针灸推拿医学（英文版）

Objective: To observe the clinical efficacy of herb-partitioned spreading moxibustion at Baliao points plus climen for diminished ovarian reserve (DOR). Methods: A total of 60 patients with DOR were randomized into a spreading moxibustion group and a Western medicine group by the random number table method, with 30 cases in each group. The Western medicine group was treated with climen, starting from the 5th day of the menstrual cycle for 21 d. The spreading moxibustion group was treated with herb-partitioned spreading moxibustion at Baliao points on the basis of the medication in the Western medicine group, 1 h per time, once a week. The treatment was performed for 1 month as one treatment course in both groups, for 3 courses in total. The serum follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) in the patients were measured before and after treatment. The peak systolic velocity (PSV) and resistance index (RI) were also detected. The traditional Chinese medicine (TCM) symptom score was evaluated. The clinical efficacy was evaluated after treatment. Results: The total effective rate in the spreading moxibustion group was 93.3％, which was significantly higher than 80.0％ in the Western medicine group, and the difference between the groups was statistically significant (P<0.05). After treatment, the TCM symptom scores, the serum FSH levels, FSH/LH ratios and RI in both groups decreased, and the intra-group differences were all statistically significant (all P<0.05). The serum E2 level and PSV increased compared with those in the same group before treatment, and the intra-group differences were statistically significant (all P<0.05). After treatment, the TCM symptom score, the serum FSH level, FSH/LH ratio and RI in the spreading moxibustion group were lower than those in the Western medicine group, while the serum E2 level and PSV were higher than those in the Western medicine group, and the differences between the groups were statistically significant (all P<0.05). Conclusion: Herb-partitioned spreading moxibustion at Baliao points plus climen can produce valid therapeutic efficacy for DOR. It can improve the clinical symptoms, regulate serum hormone levels and increase ovarian blood perfusion, thus improving ovarian reserve function, producing more significant efficacy than climen alone.

Criteria, diagnosis and treatment of decreased ovarian function: Recent progress / 第二军医大学学报

Fallopian tube factors and decreased ovarian function are the main causes of female infertility. Decreased ovarian function includes premature ovarian failure, diminished ovarian reserve, premature ovarian insufficiency and poor ovarian response. The main feature of ovarian function decline is the decrease in the number and/or the low quality of ova, manifested as ovulation disorders, infertility and reproductive endocrine disorders. This article summarizes the progress in different evaluation criteria and treatment of decreased ovarian function, hoping to provide reference for future diagnosis and treatment.

Effect of moxibustion pretreatment at different time on ovarian function in rats with dimini-shed ovarian reserve / 针刺研究

OBJECTIVE: To observe the effect of moxibustion pretreatment at different time on serum hormone levels in diminished ovarian reserve (DOR) rats, so as to explore its protective mechanisms. METHODS: Forty female SD rats were randomly divided into control, model, moxibustion-1 (moxibustion was given 4 weeks before modeling), moxibustion-2 (moxibustion was given 2 weeks before modeling and 2 weeks from the 1st day on after modeling ) and moxibustion-3 (moxibustion was given 4 weeks from the 1st day on after modeling) groups (n=8 rats in each group). The DOR model was established by gavage of Tripterygium Glycosides (75 mg/kg) once daily for 14 days. Grain-moxibustion was applied to "Shenshu" (BL23) and "Guanyuan" (CV4) for 7 cones, 5 times a week for 4 weeks. The body weight and the ovary weight were recorded for calculating the ovarian index. The levels of serum anti-mullerian hormone (AMH), follicle stimulating hormone (FSH), estradiol (E2), androgen (T) and dehydroepiandrosterone (DHEA) were detected by ELISA. RESULTS: After modeling, ovarian index and serum AMH levels were obviously decreased (P<0.05), and the levels of serum FSH, E2, T and DHEA were significantly increased in contrast with the control group (P<0.05). Following intervention and compared with the model group, the serum FSH and DHEA levels of each moxibustion group were significantly reduced (P<0.05), the AMH levels significantly increased and E2 and T contents significantly decreased in the moxibustion-2 and moxibustion-3 groups (P<0.05). The serum FSH, E2 and T contents in moxibustion-2 group were obviously lower than those of the moxibustion-1 and moxibustion-3 groups (P<0.05). CONCLUSION: Moxibustion pre-treatment can improve ovarian reserve function in DOR rats, while the effect is different with different intervention time, and the best intervention time is pre-occurrence and early stage of DOR.

Theoretical and Clinical Studies of Integrated Traditional Chinese Medicine and Western Medicine for Infertile Women with Diminished Ovarian Reserve / 中国实验方剂学杂志

Infertility with diminished ovarian reserve(DOR) is a major problem in the field of reproductive health and it has attracted great attention worldwidely.Function deficiency of the kidney is one of the fundamental pathogenesis for DOR.Traditional Chinese medicines(TCMs) have a long history with rich experience for the treatment of infertility.Some TCMs are very effective in the treatment of kidney deficiency for infertility with DOR.The integrated TCMs and western medicine,and combination of disease differentiation and syndrome differentiation may help for diagnosis and treatment of infertility with DOR.We adopt the concept of unified treatment for special disease,and the methods and principle of treatment can be used.Therefore,we adopt the TCM concept of kidney-tonifying,blood-nourishing,liver-dispersing and spleen-invigorating.The TCMs kidney-tonifying formulae are added and subtracted.TCMs can regulate the reproductive function via multiple systems for simultaneous conditioning of follicular development and ovulation.At the same time,a hypothesis of " simultaneous conditioning of follicular development and ovulation" was proposed.Two-stage therapy with integrated TCMs and western medicine has been used,mainly for increasing the number of eggs,and improving follicle quality.The goal is to achieve simultaneous conditioning of follicular development and ovulation and ultimately for effective treatment of infertility with DOR.

Effect of Nourishing Yin and Nonifying Yang Sequential Therapy Combined with Western Medicine on Expression Levels of Smad2 ,Smad3 ,Smad7 mRNA in Rats with Diminished Ovarian Reserve / 华中科技大学学报(医学版)

Objective To investigate the effect of Nourishing Yin and Nonifying Yang sequential therapy (NYNYST )com-bined with western medicine on expression levels of Smad2 ,Smad3 ,Smad7 mRNA in rats with diminished ovarian reserve (DOR).Methods Totally 40 female rats were randomly divided into 5 groups ,the normal control group ,the model group ,the western medicine group ,the NYNYST group and the combination group(western medicine combined with NYNYST ) ,8 in each group. The DOR model was established through orally administering tripterygium pill for continuous 2 weeks. The normal con-trol group and the model group were administered with saline for 10 days. The western medicine group was treated with hor-mone replacement therapy(HRT ) and ovarian stimulation. The NYNYST group was administered with Nourishing Yin herbs in proestrus and Nonifying Yang herbs in late estrus and the combination group was administered with combination of Chinese herb and western drugs for 10 days ,with the same dose in the former two groups.Serum levels of FSH ,LH ,E2 ,anti-Müllerian hormone(AMH) ,Transforming growth factor beta 1(TGF-β1)and Inhibin B(INHB)were measured by ELISA.Changes of Smad2 ,Smad3 ,Smad7 mRNA in ovaries were detected by real-time PCR.Results Compared with the model group ,the serum levels of FSH ,LH were decreased significantly in western medicine group ,NYNYST group and combination group(P＜0.01) , the serum levels of E2 ,AMH ,TGF-β1 and INHB increased in the rats of the treatment group(P＜0.05 ,P＜0.01) ,and efficacy of the combination group was significantly superior to that of the western medicine group (P＜0.01 ,P＜0.05);compared with the model group ,Smad2 mRNA increased significantly in NYNYST group and combination group ,Smad3 mRNA increased sig- nificantly in combination group(P＜0.01) ,the efficacy of combination group was superior to that of the western medicine group (P＜0.05);compared with the model group ,Smad7 mRNA of treatment groups was decreased significantly (P＜0.01).Conclu-sion NYTYST combined with western medicine can improve the function of ovaries by up-regulating the expression of Smad2 , Smad3 mRNA and down-regulating the expression of Smad7 mRNA in DOR rats.

Efficacy of Jiajian Yijing Decoction on improving clinical symptoms and pregnancy rate of patients with diminished ovarian reserve and kidney deficiency and hepatic depression syndrome / 实用医学杂志

Objective To observe the clinical efficacy of Jiajian Yijing Decoction on improving clinical symptoms and pregnancy rate of patients with diminished ovarian reserve(DOR)and kidney deficiency and hepat-ic depression syndrome. Methods Patients with DOR and kidney deficiency and hepatic depression syndrome were randomly divided into traditional Chinese medicine group(n = 33)and western medicine group(n = 34). Patients in TCM group were treated with Jiajian Yijing Decoction and those in western medicine group with artificial periodic therapy(Progynova 2 mg/d+Dydrogesterone 20 mg/d).All cases were treated with 3 menstrual cycles.The improvement of clinical symptoms of DOR and kidney deficiency and hepatic depression syndrome and pregnancy rate were observed. Results The improvement of clinical symptoms of DOR and kidney deficiency and hepatic depression syndrome after treatment in TCM group was more obvious than that in western medicine group(P<0.05 or P < 0.01). The pregnancy rate after treatment in TCM group was higher than that in western medicine group, but it had no statistic difference(P>0.05).Conclusions Jiajian Yijing Decoction can obviously improve the clin-ical symptoms of patients with DOR and kidney deficiency and hepatic depression syndrome and increase the preg-nancy rate in infertile patients.It is worthy of clinical popularization.