It has been proposed that gonadotoxic chemotherapy results in the “burn out” of primordial follicle reserve by activating PI3K/PTEN/Akt signaling pathway. Others have challenged this concept and put forward DNA damage and apoptosis as the main mechanism of follicle loss. We conducted this study to answer this controversy and conclusively determine the mechanism of chemotherapy-induced damage to ovarian reserve in women. Ovarian cortical pieces from organ donors aged ≤32 years were xenografted subcutaneously to SCID mice (n=12 mice/ tissue from 4 donors each). After 10 days, the mice were given an injection of cyclophosphamide (75mg/kg) or the vehicle. The tissues were recovered 12 hours later. The recovered xenografts were assessed for apoptosis by anti-caspase-3 (AC3) and DNA double strand breaks by γ-H2AX immunostaining as well as follicle growth initiation rate (FGIR) by primary/primordial follicle ratios. Single primordial follicle oocytes were laser captured for RNA sequencing and single cell quantitative real time PCR (qRT-PCR) to determine the signaling pathways activated in response to chemotherapy exposure. Immunofluorescence microscopy and image analysis were used to assess phosphorylation of PI3K/PTEN/Akt pathway and Bad-Bcl2 co-localization. There was no difference in the primordial follicle growth initiation rate (FGIR) between the vehicle and the cyclophosphamide-treated xenografts (p=0.35). However, cyclophosphamide caused a significant increase in the percentage of apoptotic (65.02±3.55% vs. 28.27±5.77%; p=0.001) and DNA-damaged (82± 2.7% vs. 23.82±8.66%;p=0.0001) primordial follicles . Ingenuity Pathway Analysis (IPA) of the RNA sequencing data from laser captured primordial follicles showed significant decrease in the expression of PECAM (p=0.00009), IKBKE (P=0.0001), and ANGPT1 (p=0.003) after cyclophosphamide treatment. These are positive regulators of the Akt pathway and hence results indicate that cyclophosphamide suppresses rather than activating Akt. In addition, IPA predicted that suppression of these pathways favor apoptosis in single primordial follicles. By qRT-PCR analyses, there was no change in the expression of Akt (p=0.9). Further, cyclophosphamide treatment did change the expression of the phospho-Akt (P=0.14), phospho-Foxo3a (p=0.17), or phospho-rpS6 (0.48) compared to the vehicle. By qRT-PCR, chemotherapy increased the expression of the anti-apoptotic Bcl2 (p=0.0003) accompanied by enhanced colocalization of the pro-apoptotic BAD-Bcl2 complex (p=0.006) in the primordial follicles, confirming that cyclophosphamide induces follicle death via apoptosis. This single cell transcriptomic and immunohistochemical analysis of human primordial and primary follicles prove that gonadotoxic chemotherapy agents do not cause follicle activation; they rather create a pro-apoptotic state resulting in massive loss of ovarian reserve. Future research on pharmacological fertility preservation should target preventing DNA damage and apoptosis rather than follicle activation.
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