VIEWS AND REVIEWS

Aging gonads, glands, and

gametes: immutable or partially
reversible changes?
David R. Meldrum, M.D.
Reproductive Partners Medical Group, Redondo Beach, California

Decreased ovarian testosterone production, granulosa cell dysfunction, oocyte telomere shortening and mitochondrial defects, and
sperm DNA fragmentation all contribute to reproductive aging. Maneuvers aimed at correcting
these abnormalities, including reduction of oxidative stress, improved lifestyle and nutrition,
and the role of supplements, are reviewed. (Fertil Steril 2013;99:14. 2013 by American Use your smartphone
Society for Reproductive Medicine.) to scan this QR code
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A
s you read through the follow- whereas in our patients with polycystic years, insulin-like growth factor (IGF)
ing ve reviews (15), you ovary syndrome (PCOS), success with I has been identied as a major player
will appreciate that the effects IVF is preserved even entering into the in GC function, but only very recently
of aging on fertility are complex, as is fth decade (1). have growth hormone and testosterone
aging itself, and therefore attempts to As the dominant follicle develops, stimulation of hepatic IGF-I production
counteract these age-related changes the huge increase of oocyte cytoplasm and testosterone itself been used as
requires a multifaceted approach. and its critical mass of mitochondria ways to improve GC health (1).
As outlined in the rst review, by depend almost entirely on the health Bob Casper and his group from Tor-
me and coauthors (1), the number of of the granulosa cells (GCs) that sur- onto, Canada, delve into the intricacies
antral follicles available for stimulation round and nourish the oocyte. Carla of mitochondrial function and the de-
for fertility treatments depends in part Tatone and her team in Naples, Italy, ciencies which characterize the aging
on the local ovarian effects of testoster- describe in her review (2) how GCs, par- oocyte (3). Just as with aging in gen-
one, IGF-I, and insulin, helping to ex- ticularly in older women, are adversely eral, oxidative stress has a signicant
plain the remarkably wide variation of affected by oxidative stress (including role. Mitochondria are the cells fur-
antral follicle count (AFC) and anti- advanced glycation end-products), nace, churning out reactive oxygen
mullerian hormone (AMH) values at resulting in reduced proliferation and species (ROS), and added oxidative
any particular age. Superimposed on increased cell death (apoptosis). The stress can lead to a mini-meltdown
that variability are age-related oocyte complement of mitochondria achieved where ROS damage the reactor itself,
depletion and a gradual fall in ovarian in the oocyte during that remarkable resulting in even more ROS accumula-
testosterone production starting before growth phase must be sufcient for tion. This group of investigators is on
the fourth decade. Paradoxically, it is energy-intense chromosome realign- the verge of dening a way to improve
our insulin-sensitive patients, whose ments and early cell divisions of the oo- mitochondrial function in aging oo-
health we would consider to be more cyte and early embryo, until nally at cytes using Coenzyme Q-10, hopefully
optimal, who manifest more of a decline the blastocyst stage the mitochondria translating the clear benecial effects
of FSH-sensitive antral follicles, again start to replicate (3). For many seen in their aging rat model to
humans. Coenzyme Q-10 may even
Received October 20, 2012; accepted October 21, 2012; published online November 17, 2012.
D.R.M. is a shareholder of Sexuality Education Network, LLC, which operates the website
correct chromosome misalignments
www.lifechoicesandfertility.com. characteristic of the older oocyte.
Reprint requests: David R. Meldrum, M.D., Reproductive Partners Medical Group, 510 N. Prospect David Keefe and his team have had
Ave., Suite 202, Redondo Beach, CA, 90277 (E-mail: drmeldrum@gmail.com).
a long interest in the process of chro-
Fertility and Sterility Vol. 99, No. 1, January 2013 0015-0282/$36.00 mosome realignment in the oocyte
Copyright 2013 American Society for Reproductive Medicine, Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.fertnstert.2012.10.044
and the role of telomeres in anchoring

VOL. 99 NO. 1 / JANUARY 2013 1

VIEWS AND REVIEWS
that process (4). Their review gives fascinating insights into
the role of oocyte telomere shortening in the poor oocyte per-
formance of older women, and the possible effect of telomere
lengthening in early preimplantation embryos in limiting
complications of pregnancy. Again, oxidative stress plays
a role in telomere shortening. Most likely, the shorter oocyte
telomere length in older women is the result of a long-term
process inuenced during the many years that oocytes remain
in limbo in this era of delayed childbirth (4). Better life choices
during those many years of delay may be one of the keys to
fertility preservation and perhaps even less complicated preg-
nancies and a reduced risk of gynecologic cancer. Avoidance
of oxidative stress may also be critical during early embryo
development, adding emphasis to the importance of ideal cul-
ture conditions, such as a reduced oxygen environment, to
limit pregnancy complications as well as increase successful
implantation. The choice of whether a cleavage or blastocyst
transfer is optimal may depend on the quality of the maternal
environment as well as that of the laboratory. Finally, the
nding that sperm telomeres are longer in older men allows
us to reassure them that their reduced fertility is at least partly
counterbalanced by increased longevity of their offspring.
Sperm also suffer negative effects of aging, in addition to
the well known mild increase of genetic defects in older mens
offspring. Denny Sakkas and his coauthor outline evidence
showing that the sperm of older men contribute to lower preg-
nancy success, particularly when matched with the older egg
(5). Sperm DNA fragmentation increases with age, and in one
study it was seen only under specic (alkaline) conditions,
indicating that it may not be detected by all assays. Again,
oxidative stress appears to be the most likely culprit. Unfortu-
nately the older oocyte may be less able to repair sperm DNA
breaks (5). In a study from France, male age varied widely,
coupled with younger and older women. The effect of older
male age on the odds of failing to be successful with IVF
with women aged 3537 years was only twofold, but when
the age of the woman was R41 years the odds exceeded ve-
fold (6). At least we can reassure most of our older infertile
couples that both partners shoulder the blame for their im-
paired prognosis. Attempts to rejuvenate the older oocyte,
e.g., with the use of growth hormone or through better life-
style choices, may improve pregnancy outcome in part by im-
proving the ability of those older eggs to rescue their partners
DNA. The variable effects of male age among studies (5) may
have been inuenced by lifestyle and nutrition (see below) of
the men and women in those investigations.
Are these aging changes immutable or do we have any
ability to reverse them? In addition to describing the current
state of knowledge, reviews succeed if they stimulate our
readers to design and carry out high-quality studies to ad-
vance the treatments available to our infertile couples. I and
my coauthors discussed the nascent attempts to alter the en-
docrine/paracrine environment within the ovary to improve
numbers and function of recruited oocytes (1). It is hoped
that our discussion will stimulate much more research on
the promising modalities outlined, including the possibility
of combining treatments.
It should be evident from the above discussion that a com-
mon thread of reproductive aging involves oxidative stress
2 VOL. 99 NO. 1 / JANUARY 2013
(OS). OS is the most thoroughly researched and most well ac-
cepted theory for aging of various body systems (7). The
oxidant-antioxidant balance in the body is extraordinarily
complex, but aging basically comes down to damage by
ROS to body proteins, lipids, DNA, telomeres, and mitochon-
dria (7). Lower dietary content of antioxidants has been found
to be associated with reduced semen quality (8), and diets
containing more antioxidants have been associated with
greater pregnancy success in women (9, 10). The lifestyle
habits of many men and women (e.g., lack of physical
activity, overeating and high-sugar and high-fat diets)
promote oxidative stress (11). Overcooking of foods, which
creates advanced glycation end-products (AGEs) is also ex-
tremely common. AGEs accumulate with age and promote
OS. Excessive caloric intake stokes the mitochondrial embers,
releasing more ROS (12), whereas caloric restriction is one of
the most successful models shown to counteract the aging
process (7), and in rodents it extends the span of fertility
(13). Obesity increases with age and is commonly associated
with a 50%100% increase of calorie intake just to maintain
weight, thus offering a partial explanation for the reduced
fertility associated with obesity. It is interesting that hyperan-
drogenic and insulin-resistant women with PCOS have
a mean 40% decrease of their basal metabolic rate (14), which
may contribute to their more favorable prognosis as they
age (1).
Increased OS in semen correlates with increased male age,
with reduced sperm motility and with increased sperm DNA
fragmentation (5). In a well designed study, high daily doses
of antioxidants for 2 months (1 g/d vitamins C and E) reduced
sperm DNA fragmentation from 22% to 9% (P< .001) com-
pared with no change with placebo (15).
Increased OS in follicular uid correlates with increasing
female age, GC apoptosis, reduced oocyte and embryo quality,
and reduced pregnancy success with IVF (2). One of the most
important deciencies of antioxidant defenses in aging cells
is in the production of glutathione, which is reversible with
antioxidant (16). Depletion of glutathione induces GC apo-
ptosis (17), and increased GC apoptosis has a very strong re-
lationship with reduced embryo quality and failed embryo
implantation (18, 19).
It is difcult to separate the direct effects of OS on repro-
ductive functions on a cellular level from its effect in reducing
blood ow to tissues, another prime theory of aging. The prin-
cipal signaling molecule determining blood ow is nitric
oxide (NO), and NO production and stability are remarkably
sensitive to ROS and require extensive antioxidant protection.
Together with Louis J. Ignarro, Ph.D., who shared the Nobel
Prize for dening the role of NO in vascular function, my
coauthors and I have described the role of NO and lifestyle
choices in erectile and vascular function in a series of reviews
(11, 20, 21). The most striking example of the role of OS on NO
we illustrated was the profound impact of the oxidative stress
of smoking on reducing forearm blood ow (11, 20), and
smoking by both the male and female partners signicantly
reduces IVF outcome (22, 23). High doses of vitamins C and
E for almost 6 months, similar to those used for reducing
sperm DNA fragmentation discussed above, returned
forearm blood ow to above baseline (11, 20). In

placebo-controlled studies of a commercial preparation of an-
tioxidants, pycnogenol (Horphag Research and Natural
Health Science), together with a moderate dose of L-arginine
(the direct precursor for NO), improvements of sperm density,
motility, morphology, and circulating testosterone were ob-
served (all P< .001) (21), suggesting global effects on testicu-
lar blood ow as well as direct effects protecting sperm from
damage by ROS.
Recent studies of omega-3 fatty acids have shown corre-
lations with improved sperm morphology (24), with men in
the highest third of intake having a 1.9% greater strict mor-
phology than men in the lowest third (P .02). Omega-3s in-
crease NO (20), decrease vasoconstricting prostanoids (25),
reduce oxidative stress and increase antioxidant capacity
(26), and augment antioxidant defenses in semen (27). In
a randomized trial, 1,840 mg/d of omega-3s for 32 weeks in-
creased mean sperm concentration from 16.2 to 28.7 million
per mL (P< .001) and mean strict morphology from 7.5% to
12.8% (P< .002) (27). In a study of the dominant follicle, sur-
rounding blood ow measured by 3D Doppler had a striking
relationship to successful pregnancy (28). In infertile women,
hair mercury levels, which were strongly correlated with sh
consumption (and therefore omega-3s), correlated with
improved embryo implantation (29). Ovarian blood ow has
also been found to correlate positively with the number of fol-
licles responding to stimulation, and resistance to ow corre-
lated negatively with AFC (30). Regular moderate exercise,
which stimulates NO, improves blood ow, and reduces oxi-
dative stress (31), has been correlated with enhanced female
fertility and improved semen parameters compared with a sed-
entary lifestyle (32, 33). Although evidence of reduced blood
ow to reproductive organs with aging is lacking (29, 30),
measures aimed at augmenting testicular and ovarian blood
ow may be more critical for older infertile men and
women, whose gametes are already compromised.
As this area continues to develop, important new informa-
tion is rapidly accumulating on the profound effects of lifestyle
choices and nutrition on fecundity and the chance of being
successful with fertility treatments. In our own group, we
have faced the difcult task in making our infertile couples
fully aware of this rapidly advancing eld. I have therefore
constructed a website, www.lifechoicesandfertility.com, which
provides couples with up-to-date information, including short
descriptions of pertinent references with links to their Pubmed
abstracts (34). I would encourage any of our readers to avail
themselves of this resource for their infertile couples.
The potential for improving the fertility and IVF success
of our older couples is exciting. We will be able to partially
turn back the clock for many of these patients, but the real
value of the present review may be to emphasize that better
life choices must be made throughout the period when a wom-
ans oocytes are lying in waiting, and at the very latest as soon
as she and her partner begin their efforts to conceive. All that
is required of us is to provide them with timely information
and motivation. Because those better choices will also im-
prove erectile function, vascular health, and longevity, may
reduce the pregnancy complications and gynecologic cancers
linked to infertility, and may even inuence the longevity and
health of their offspring (4), it is difcult to imagine anything
VOL. 99 NO. 1 / JANUARY 2013
Fertility and Sterility
more worthwhile for younger couples planning to delay their
families.
REFERENCES
1. Meldrum DR, Chang RJ, Giudice LC, Balasch J, Barbieri RL. Role of decreased
androgens in the ovarian response to stimulation in older women. Fertil
Steril 2013;99:511.
2. Tatone C, Amicarelli F. The aging ovarythe poor granulosa cells. Fertil
Steril 2013.
3. Bentov Y, Casper RF. The aging oocytecan mitochondrial function be
improved? Fertil Steril 2013;99:1822.
4. Kalmbach KH, Antunes DMF, Dracxler RC, Knier TW, Seth-Smith ML, Wang F,
et al. Telomeres and human reproduction. Fertil Steril 2013;99:239.
5. Humm KC, Sakkas D. Role of increased male age in IVF and egg donation
is sperm DNA fragmentation responsible? Fertil Steril 2013;99:306.
6. de la Rochebrochard E, de Mouzon J, Thepot F, Thonneau P, French National
IVF Registry (FIVNAT) Association. Fathers over 40 and increased failure to con-
ceive: the lessons of in vitro fertilization in France. Fertil Steril 2006;85:14204.
7. Kregel KC, Zhang HJ. An integrated view of oxidative stress in aging: basic
mechanisms, functional effects and pathological considerations. Am J Phys-
iol Regul Integr Comp Physiol 2007;292:R1836.
8. Mendiola J, Torres-Cantero AM, Vioque J, Moreno-Grau JM, Ten J, Roca M,
et al. A low intake of antioxidant nutrients is associated with poor semen
quality in patients attending fertility clinics. Fertil Steril 2010;93:122833.
9. Twigt JM, Bolhuis MEC, Steegers EAP, Hammiche F, van Inzen WG,
Laven JSE, Steegers-Theunissen RPM. The preconception diet is associated
with the chance of ongoing pregnancy in women undergoing IVF/ICSI treat-
ment. Hum Reprod 2012;27:252631.
10. Vujkovic M, de Vries JH, Lindemans J, Macklon NS, van der Spek PJ, Steegers-
Theunissen RPM. The preconception Mediterranean dietary pattern in cou-
ples undergoing in vitro fertilization/intracytoplasmic sperm injection treat-
ment increases the chance of pregnancy. Fertil Steril 2010;94:2096101.
11. Meldrum DR, Gambone JC, Morris MA, Esposito K, Giugliano D, Ignarro LJ.
Lifestyle and metabolic approaches to erectile and vascular health. Int J Im-
pot Res 2012;24:618.
12. Igosheva N, Abramov AY, Poston L, Eckert JJ, Fleming TP, Duchen MR, et al.
Maternal diet-induced obesity alters mitochondrial activity and redox status
in oocytes and zygotes. PloS One 2010;5:e10074.
13. Selesniemi K, Lee H-J, Tilly JL. Moderate caloric restriction in rodents during
adulthood sustains function of the female reproductive axis into advanced
chronological age. Aging Cell 2008;7:6229.
14. Georgopuolos NA, Saltamavros AD, Vervita V, Karkoulias K, Adonakis G,
Decavalas G, et al. Basal metabolic rate is decreased in women with polycys-
tic ovary syndrome and biochemical hyperandrogenemia and is associated
with insulin resistance. Fertil Steril 2009;92:2505.
15. Greco E, Iacobelli M, Rienzi L, Ubaldi F, Ferrero S, Tesarik J. Reduction of the
incidence of sperm fragmentation by oral antioxidant treatment. J Androl
2005;26:34953.
16. Su JH, Shenvi SV, Dixon BM, Liu H, Jaiswal AK, Liu RM, et al. Decline in tran-
scriptional activity of Nrf2 causes age-related loss of glutathione synthesis,
which is reversible with lipoic acid. Proc Natl Acad Sci U S A 2004;101:
33816.
17. Devine PJ, Perreault SD, Luderer U. Roles of reactive oxygen species and
antioxidants in ovarian toxicity. Biol Reprod 2012;86:27.
18. Elgindy EA, El-Huseiny A, Mostafa MI, Gaballah AM, Ahmed TA. N-Acetyl
cysteine: could it be an effective adjunct in ICSI cycles? A preliminary study.
Reprod Biomed Online 2010;20:78996.
19. Suh CS, Jee BC, Choi YM, Kim JG, Lee JY, Moon SY. Prognostic implication
of apoptosis in human luteinized granulosa cells during IVF-ET. J Assist
Reprod Genetics 2002;19:20914.
20. Meldrum DR, Gambone JC, Morris MA, Meldrum DA, Esposito K, Ignarro LJ.
The link between erectile and cardiovascular health: the canary in the coal
mine. Amer J Cardiol 2011;108:599606.
21. Meldrum DR, Gambone JC, Morris MA, Ignarro LJ. A multifaceted approach
to maximize erectile function and vascular health. Fertil Steril 2010;94:
251420.
3
VIEWS AND REVIEWS
22. Zitzmann M, Rolf C, Nordhoff V, Schrader G, Rickert-Fohring M, Gassner P,
et al. Male smokers have a decreased success rate for in vitro fertilization and
intracytoplasmic sperm injection. Fertil Steril 2003;79:15504.
23. Hughes EG, Yeo J, Claman P, Younglai EV, Sagle MA, Daya S, Collins JA.
Cigarette smoking and the outcomes of in vitro fertilization: measurement
of effect size and levels of action. Fertil Steril 1994;62:80714.
24. Attaman JA, Toth TL, Furtado J, Campos H, Hauser R, Chavaro JE. Dietary fat
and semen quality among men attending a fertility clinic. Hum Reprod 2012;
2:146674.
25. Kris-Etherton PM, Harris WS, Appel LJ. American Heart Association Nutrition
Committee. Fish consumption, sh oil, omega-3 fatty acids, and cardiovas-
cular disease. Circulation 2002;106:274757.
26. Nalsen C, Vessby B, Berglund L, Uusitupa M, Hermensen K, Riccardi G, et al.
Dietary (n-3) fatty acids reduce plasma F2-isoprostanes but not prostaglan-
din F2a in healthy humans. J Nutr 2006;136:12228.
27. Safarinejad MR. Effect of omega-3 polyunsaturated fatty acid supplementa-
tion on semen prole and antioxidant capacity of seminal plasma in infertile
men with idiopathic oligoasthenoteratospermia: a double-blind, placebo-
controlled, randomized study. Andrologia 2011;43:3847.
4 VOL. 99 NO. 1 / JANUARY 2013
28. Lozano DH, Frydman N, Levaillant JM, Fay S, Frydman R, Fanchin R. The 3D
vascular status of the follicle after hCG administration is qualitatively rather
than quantitatively associated with its reproductive competence. Hum
Reprod 2007;22:10959.
29. Wright DL, Smith KW, Ehrlich S, Berry K. Maternal hair mercury levels and
early in vitro fertilization (IVF) outcomes. Fertil Steril 2011;96(Suppl):S7.
30. Jadeon JE, Ben-ami N, Haddad S, Radin O, Bar-ami S, Younis JS. Prospective
evaluation of early follicular ovarian stromal blood ow in infertile women
undergoing IVF-ET treatment. Gynecol Endocrinol 2012;28:3569.
31. Ignarro LJ, Balestrieri ML, Napoli C. Nutrition, physical activity and cardiovas-
cular disease: an update. Cardiovasc Res 2007;73:32640.
32. Wise LA, Rothman KJ, Mikkelsen EM, Sorensen HT, Riis AH, Hatch EE. A pro-
spective cohort study of physical activity and time to pregnancy. Fertil Steril
2012;97:113642.
33. Vaamonde D, da Silva-Grigoletto ME, Garcia-Manso JM, Barrera N, Vaa-
monde-Lemos R. Physically active men show better semen parameters and
hormone values than sedentary men. Eur J Appl Physiol 2012;112:326773.
34. Meldrum DR. Life choices and fertility. Available at: http://lifecoicesandfertility.
com. Accessed October 7, 2012.