Center for Reproductive Medicine - Innovations in Female Infertility Research

INNOVATIONS IN FEMALE INFERTILITY RESEARCH

Cleveland Clinic's Center for Reproductive Medicine
1993 - 2008

Understanding oxidative stress and female reproduction

Figure:
Free Radicals and Gametes

Over the last decade we have defined the role of oxidative stress and its implications in female reproduction and reproductive diseases. We have been innovative in increasing our understanding of the nature of oxidative stress, its causes and the factors that influence it, as well as the role of antioxidants and their effects on infertility, fertilization, pregnancy and other pregnancy-associated diseases such as preeclampsia etc. Oxidative stress is one of the main underlying mechanisms in the pathogenesis of a continuum of disease processes such as spontaneous abortion, hydatidiform mole, and preeclampsia. Recurrent pregnancy loss may be caused by oxidative damage. Oxidative stress and damage induced by reactive oxygen species may be the missing pieces of the puzzle in abortion and recurrent pregnancy loss of unexplained etiology. We have provided excellent review articles and book chapters to illustrate the importance of oxidative stress in female reproductive diseases.

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Agarwal A, Allamaneni SSR. (2004):
Role of free radicals in female reproductive diseases and assisted reproduction. Review article.
Reprod Biomed Online 9:338-47.
PDF File (agradoc159.pdf 225 Kb)
Sharma RK, Agarwal A. (2004):
Role of reactive oxygen species in gynecologic diseases. Review article.
Reprod Med Biol 3:177-199.
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Agarwal A and Allamaneni SSR. (2004):
Significance of human sperm chromatin damage in assisted reproduction.
ART & Science 4:2-4.
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Agarwal A, Gupta S. (2005):
Role of reactive oxygen species in female reproduction. Part 1. Oxidative stress: a general overview. Review article.
AgroFOOD industry hi-tech 16:21-25.
PDF File (agradoc186.pdf 721 Kb)
Agarwal A, Gupta S, Sharma RK. (2005):
Role of oxidative stress in female reproduction. Review article.
Reprod Biol Endocrin 3:28.
PDF File (agradoc189.pdf 259 Kb)
Agarwal A, Gupta S, Sharma RK. (2005):
Oxidative stress and its implications in female infertility - a clinician's perspective. Review article.
Reprod Biomed Online 11:641-50.
PDF File (agradoc194.pdf 94 Kb)
Gupta S, Agarwal A, Sharma RK. (2005):
The role of placental oxidative stress and lipid peroxidation in preeclampsia. Review article.
Obstet Gynecol Surv 60:807-16.
PDF File (agradoc207.pdf 305 Kb)
Gupta S, Agarwal A, Krajcir, N, Alvarez JG. (2006):
Role of oxidative stress in endometriosis. Review article.
Reprod BioMed Online 13:126-134.
PDF File (agradoc217.pdf 156 Kb)
Agarwal A, Said TM, Bedaiwy MA, Banerjee J, Alvarez JG. (2006):
Oxidative stress in an assisted reproductive techniques setting. Review article.
Fertil Steril 86:503-512.

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Agarwal A, Gupta S. (2006):
The role of free radicals and antioxidants in female reproduction. Business briefing.
US Genito-Urinary Disease 2006: 60-5.
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Gupta S, Banerjee J, Agarwal A. (2006):
The impact of reactive oxygen species in early human embryos.
Embryo Talk 1.2:87-98.
PDF File (agradoc224.pdf 1086 Kb)
Gupta S, Agarwal A, Agarwa, R, Loret de Mola R. (2006):
Impact of ovarian endometrioma on assisted reproduction outcomes. Review article.
Reprod BioMed Online 13:349-360.
PDF File (agradoc226.pdf 268 Kb)
Agarwal A, Gupta S, Abdel-Razek H, Krajcir N, Athayde K. (2006):
Impact of oxidative stress on gametes and embryos in an ART laboratory. Review article.
Clin Embryol 9:5-22.
PDF File (agradoc231.pdf 150 Kb)
Gupta S, Agarwal A, Sekhon L, Krajcir N, Cocuzza M, Falcone T. (2006):
Serum and peritoneal abnormalities in endometriosis: potential use as diagnostic markers. Review article.
Minerv Ginecol 58:527-51.
PDF File (agradoc254.pdf 685 Kb)
Gupta S, Agarwal A, Banerjee J, Alvarez JG. (2007):
The role of oxidative stress in spontaneous abortion and recurrent pregnancy loss: A Systematic Review.
Obs & Gyn Survey 62: 335-47 CME Review Article.
Krajcir N, Chowdary H, Gupta S, Agarwal, A. (2007):
Female infertility and ART: impact of oxidative stress. Review article.
Cur Wom Health Rev. (In Press)
Gupta S, Aziz N, Agarwal A. (2007):
The impact of oxidative stress on female reproduction and ART: an evidence- based review.
In: Textbook of Infertility and Assisted Reproduction.(Editors: Botros Rizk; Juan A. Garcia-Velasco; Hassan Sallam; Antonis Makrigiannakis), Cambridge University Press. (In Press).

Role of oxidative stress in female infertility

Figure:
Implications of Oxidative Stress In Female Infertility

We have demonstrated the impact of elevated reactive oxygen species (ROS) levels in a variety of fluid samples from various microenvironments in the reproductive tract, such as follicular, peritoneal, hydrosalpingeal and amniotic fluid, on fertility outcomes. In addition, we have demonstrated the presence of lipid peroxidation or total antioxidant levels in these fluids. An increase in ROS levels or a reduction in antioxidant level results in oxidative stress, which has been implicated in the pathogenesis of infertility and other reproductive diseases.

PDF File (agradoc044.pdf 583 Kb)
Wang Y, Sharma RK, Falcone T, Goldberg J, Agarwal A. (1997):
Importance of reactive oxygen species in the peritoneal fluid of women with endometriosis or idiopathic infertility.
Fertil Steril, 68:826-830.
PDF File (agradoc88.pdf 59 Kb)
Attaran M, Pasqualotto E, Falcone T, Goldberg J, Miller K, Agarwal A, Sharma RK. (2000):
The effect of follicular fluid reactive oxygen species on the outcome of in vitro fertilization.
Int J Fertil Womens Med 45:314-320.

Burlingame JM, Esfandiari N, Sharma RK, Mascha E, Falcone T.
Total antioxidant capacity and reactive oxygen species in amniotic fluid.
Obstet Gynecol. 2003 Apr;101(4):756-61.
PDF File (agradoc180.pdf 76 Kb)
Bedaiwy MA, Falcone T, Goldberg JM, Attaran M, Sharma RK, Mille K, Nelson DR, Agarwal A. (2005):
Relationship between cytokines and the embryotoxicity of hydrosalpingeal fluid.
J Assist Reprod Genet 22:161-5.

Figure:
Oxidative stress in peritoneal environment

A. Endometriosis, peritoneal environment, and oxidative stress

Endometriosis has been reported to alter oocyte maturation and immunological function, cause sperm dysfunction, reduce fertilization and implantation, and impair embryogenesis. Any or all of these may adversely affect fertility. We have investigated the mechanisms of infertility associated with endometriosis, including abnormal folliculogenesis, elevated oxidative stress (OS), altered immune function and hormonal milieu in the follicular and peritoneal environments, and reduced endometrial receptivity. These factors lead to poor oocyte quality and impaired fertilization and implantation.

We demonstrated for the first time increased levels of ROS in the peritoneal fluid of women with endometriosis, although the levels were not significantly different from those in the disease-free controls. We have examined non-invasive alternatives to diagnose the disease utilizing oxidative stress markers as well as levels of various cytokines in the serum and peritoneal fluid to study the cause of low fertility outcomes in such patients.

PDF File (agradoc105.pdf 86 Kb)
Bedaiwy MA, Falcone T, Sharma RK, Goldberg JM, Attaran M, Nelson DR, Agarwal A. (2002):
Prediction of endometriosis with serum and peritoneal fluid markers: a prospective controlled trial.
Hum Reprod 17:426-431.
PDF File (endoinf09.pdf 43 Kb)
Falcone T, Mascha E. (2003):
The elusive diagnostic test for endometriosis.
Fertil Steril, 80:886-888.
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Bedaiwy MA, Falcone T. (2003):
Peritoneal fluid environment in endometriosis: clinicopathological implications. Review Article.
Minerva Ginecol, 55:333-345.

PDF File (agradoc231.pdf 150 Kb)
Gupta S, Agarwal A, Sekhon L, Krajcir N, Cocuzza M, Falcone T. (2006):
Serum and peritoneal abnormalities in endometriosis: potential use as diagnostic markers. Review Article.
Minerv Ginecol 58:527-51.
Gupta S, Goldberg J, Aziz N, Goldberg E, Krajcir N, Agarwal A. (2008):
Pathogenic mechanisms in endometriosis - assisted infertility. Review article.
Modern, Trends, Fertil Steril (In Press)

B. Alterations in peritoneal immune function

We examined peritoneal fluid leptin levels in women with endometriosis and demonstrated higher levels of leptin in peritoneal fluid of patients with endometriosis compared to those without. The data suggest the pro-inflammatory and neoangiogenic action of leptin may contribute to the pathogenesis of endometriosis and endometriosis-associated pain. We have demonstrated that serum IL-6 and peritoneal fluid TNF-a as non-surgical diagnostic tool.

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Bedaiwy MA, Falcone T, Goldberg JM, Sharma RK, Nelson DR, Agarwal A. (2006):
Peritoneal fluid leptin is associated with chronic pelvic pain but not infertility in endometriosis patients.
Hum Reprod 21:788-91.
PDF File (agradoc105.pdf 86 Kb)
Bedaiwy MA, Falcone T, Sharma RK, Goldberg JM, Attaran M, Nelson DR, Agarwal A. (2002) :
Prediction of endometriosis with serum and peritoneal fluid markers: A prospective controlled trial.
Hum Reprod, 17:426-431.

Figure:
Alterations in follicular environment in women with endometriosis

C. Follicular environment and folliculogenesis in women with endometriosis

We have investigated follicular fluid IL-6 and IL-12 levels as biological markers that impact IVF outcome. We have shown that the individual cytokines in human ovarian follicular fluid play an important role in the follicular microenvironment and can be used as predictors for IVF outcome.

PDF File (agradoc249.pdf 280 Kb)
Bedaiwy M, Shahin AY, AbulHassan AM, Goldberg JM, Sharma RK, Agarwal A, Falcone T. (2007):
Differential expression of follicular fluid cytokines: relationship to subsequent pregnancy in IVF cycles.
RBM Online 15:321-25.

Figure:
OS & DNA damage in Endometriosis

D. Oxidative stress, DNA damage and endometriosis

We have demonstrated that oocytes or embryos exhibit increased levels of DNA damage when incubated in peritoneal fluid (PF) of endometriosis patients, and the extent of the damage was dependent on the duration of PF exposure. The increased DNA damage in sperm, oocyte, and resulting embryo may be responsible for increased rates of miscarriage and fertilization and implantation failures among endometriosis patients.

Mansour G, Radwan E, Sharma R, Agarwal A, Falcone T, Goldberg J.
DNA damage to embryos incubated in the peritoneal fluid of patients with endometriosis: role in infertility.
Fertility and Sterility, Vol. 88, September, 2007. pp. S311.

Figure:
Endometriosis and Oocyte quality

E. Endometriosis and oocyte quality

Oocyte spindle structure (microtubules and chromosomal alignment) is essential for a normal meiotic division. Oocytes appear to be protected against oxidative stress (OS) by oxygen scavengers that are present in vivo. However, when oocytes are removed from their natural environment, as in assisted reproductive technologies (ART), this natural defense is lost.

We have evaluated the effects of exogenous induction of OS by hydrogen peroxide and TNF-alpha on the changes in microtubular structure and chromosomal alignment to mimic the conditions that may exist in vitro and in patients with endometriosis. In addition, we demonstrated the protective effect of vitamin C supplementation in reducing OS-induced damage using MII mouse oocytes as the model. Microtubule and chromosomal changes in poor quality oocytes were seen, and this could potentially explain the reduced fertilization and reduced implantation rates. The etiology for low fertility outcomes in patients with endometriosis both in vivo and in vitro may be traced to alterations in the oocyte spindle structure and chromosomal alignment, which are essential for a normal meiotic division.

PDF File (agradoc247.pdf 1181 Kb)
Cho WJ, Banerjee J, FalconeT, Bena J, Agarwal A, Sharma RK. (2007):
Oxidative stress and TNF-a induced alterations in metaphase-II mouse oocyte spindle structure.
Fertil Steril 2007 Oct:88(4 Suppl):1220-31.
PDF File (07-A-951325-ASRM.pdf 29 Kb)
Gihan Mansour, MD, Tommaso Falcone, MD, Amal El Shahaat, MD, Ph.D, Rakesh Sharma, Ph.D, Jeffrey Goldberg, MD, Ashok Agarwal, Ph.D,HCLD:
Response of immature and mature mouse cytoskeleton to endometriosis - Role of oxidative stress.
Abstract # 951325.

PDF File (07-A-951322-ASRM.pdf 27 Kb)
Gihan Mansour, MD, Ashok Agarwal, Ph.D, HCLD, Emad Radwan, MD, Rakesh Sharma, Ph.D, Jeffrey Goldberg, MD, Tommaso Falcone, MD:
DNA damage in metaphase II oocytes is induced by peritoneal fluid from endometriosis patients.
Abstract # 951322.
PDF File (07-A-951320-ASRM.pdf 33 Kb)
Gihan Mansour, MD, Rakesh Sharma, Ph.D, Galal Lotfy, MD,Ph.D, Ashok Agarwal, Ph.D, HCLD, Jeffrey Goldberg, MD, Tommaso Falcone, MD:
Endometriosis induced alterations in the mouse oocyte cytoskeleton.
Abstract # 951320.