Problem of Female Reproductive Longevity
While human life expectancy has almost doubled over the past two centuries, the same cannot be said for female reproductive life. The age at which fertility (the ability to conceive, bear, and give birth) begins to decline and menopause begins has not changed much. Climax, which is accompanied by severe endocrine changes with three dozen discouraging symptoms, leads to a deterioration in general health and causes problems associated with old age and infirmity.
Menstrual cessation affects most women: They experience sleep and sexual dysfunction, mental and cognitive problems, all of which can last for years. Yes, women live longer on average, but the quality of menopausal life can hardly be called decent because the risks of breast cancer, cardiovascular disease, osteoporosis, and Alzheimer’s disease increase dramatically.
According to the surveys, about half of the women facing menopause were unprepared for its manifestations, such as hot flashes, sleep problems, night sweats, brain fog, increased depression, anxiety and stress. Almost all respondents expressed a desire for greater awareness of menopause.
Historically, medicine has assumed that a certain proportion of women’s misery is the norm, and therefore science has not made any serious and extensive effort to alleviate it. This is an example of neglect and segregation.
The ovaries, as the most important part of the female reproductive system, age about five times faster than any other organ. The current social and economic realities are such that women often prefer to start families and have children at a mature age. However, when the long-awaited moment arrives, the ovaries fail. Thus, by the age of 30, a woman loses approximately 90% of her original one million oocytes, and by the age of 40 she has only 3% of them left. Asynchronous ageing of ovaries leads to menopause when a woman is still relatively young and healthy.
It should be understood that the commonplace hormone replacement therapy does not solve the problem of ageing ovaries.
Of course, it is possible to resort to in vitro fertilization (IVF). But this expensive and invasive procedure has only a 20% success rate. On average, 80% of the oocytes turn out to be immature, and therefore cannot be used.
Given, first, the completely uncovered large-scale fertility market, estimated at $18 billion in 2021, amid rising overall life expectancy and, second, the growing opinion that menopause is a curable disease, investors’ optimistic interest in relevant biotech ventures will only grow stronger.
Biotech startup Oviva Therapeutics, which received $11.5 million in seed round in mid-May 2022, aims to create a therapy that makes ovulation a lifelong possibility for women. Delaying menopause will extend not only fertility but also youthfulness and health. To do this, the ageing of the ovaries should be slowed down as much as possible, preserving the supply of viable oocytes in them, thus maintaining a trouble-free menstrual cycle.
Despite the lack of a thorough understanding of what causes menopause, Oviva believes that its trigger mechanism is hormonal changes that occur as the egg reserve is depleted. It is unclear, however, why these changes put the whole body at risk of ageing.
The therapeutic target of Oviva is selected as the anti-Müllerian hormone.
- Anti-Müllerian hormone (AMH), also known as Müllerian-inhibiting substance (MIS), is a glycoprotein hormone produced by the granulosa cells of the ovaries and Sertoli cells of the testes that limits excessive growth processes in the reproductive organs of the male and female body.
- One experiments on mice showed that increasing AMH levels reduced the number of primary, secondary, and antral follicles without reducing the number of primordial follicles, indicating blockade of activation of the latter. The mice became sterile and acyclic, but retained the production of steroidal sex hormones. Other experiments on a mouse model with diminished ovarian reserve (DOR) found that the superovulation regimen combining AMH and gonadotropin resulted in a twofold increase in oocyte production.
A reversible slowing down of folliculogenesis opens new perspectives for female reproductive potential related to reliable contraception, improved positive results of in vitro fertilization (IVF), protection of the oocyte ovarian reserve during chemotherapy (at least in order to preserve the normal ovarian cyclic hormonal background if not protect fertility), prolongation of female fertility and youthfulness. For example, you can imagine a woman who takes AMH-based birth control for 10 years, and then when she stops the drug contraception, she has ovaries of a 20-year-old rather than a 30-year-old.
The experimental drug CAM-7520, which is in the preclinical stage, is a recombinant version of AMH and aims to inhibit folliculogenesis, the process by which the follicles in the ovary (each containing one egg) mature and eventually ovulate (the process of an egg leaving the ovary into the Fallopian tube as the mature follicle ruptures). This eventually leads to depletion of the oocyte pool, followed by the onset of infertility and menopause. If folliculogenesis is slowed, the depletion of the ovarian reserve can be prevented too quickly, which will be reflected in the extension of ovarian function and the duration of a healthy woman’s life. However, so far this is just a hypothesis that needs to be validated clinically.
The CAM-7520 is being developed with the help of specialists at Massachusetts General Hospital (MGH), which also provided access to the necessary patent pool.
The first CAM-7520 clinical trial, which, if approved by the U.S. Food and Drug Administration (FDA), is scheduled to start in 2022 and targets women who respond poorly to controlled ovarian hyperstimulation during IVF.
Since recombinant AMH is expensive to produce, requires frequent injections, and is characterized by low stability, the goal is to develop small-molecule compounds, modulators of folliculogenesis, available to everyone. A bet has been made on agonists of anti-Müllerian hormone receptor type 2 (AMHR2, MISR2), especially since AMH, a member of the transforming growth factor beta (TGF-β) superfamily, is unique in that it has one-to-one specificity with AMHR2. Certain developments in this direction already exist: Screening of existing drugs has identified AMHR2 agonists, such as SP600125, CYC-116, gandotinib, and ruxolitinib.
Oviva’s efforts are supported by Cambrian Biopharma, which develops drugs to prevent age-related diseases. Launched in November 2019 with a $160 million funding investment, Cambrian is trying its hand at addressing complex longevity issues related to ageing triggers, such as molecular alterations, cellular dysfunction, and tissue degeneration.
Celmatix, a 12-year-old biotech startup that has raised more than $53 million, is developing drugs to slow the depletion of the ovarian reserve. During monthly recurring menstrual cycles, the number of follicles, with a definite and finite number each woman is born with, steadily decreases.
According to Celmatix, by inhibiting follicle loss, menopause can be delayed by about a decade and a half, that is, it will move up to the age of 60–70. Just as birth control pills separate sex from procreation, so Celmatix hopes to separate women’s endocrine function from their reproductive function.
The focus of Celmatix is, as in the case of Oviva Therapeutics, on anti-Müllerian hormone (AMH).
The first clinical trial, scheduled to start in 2023, will test the hypothesis in cancer patients undergoing chemotherapy, which is one of the most common causes of premature menopause. Chemotherapy-induced ovarian failure (CIOF) develops because of exposure to chemotherapy drugs that either damage the DNA of immature follicles or cause their early activation and apoptosis, leading to accelerated depletion of the available follicle pool. An anti-Müllerian hormone receptor type 2 (AMHR2) agonist, which is in the final stages of preclinical development, could solve the problem.
At the early stage of preclinical development is a drug with exactly the opposite mechanism of action: An AMHR2 antagonist that suppresses AMH activity and is intended for the treatment of female infertility through as part of in vitro fertilization (IVF).
Celmatix cooperates with Germany’s Evotec.
The approach advocated by biotech startup Conception, wherein human induced pluripotent stem cells (iPSCs) from blood samples are transformed into mature oocytes, is seen as an alternative. In other words, the need for advance cryopreservation of eggs disappears.
In any case, experiments on mice with in vitro gametogenesis and subsequent fertilization led to the successful reproduction of healthy offspring.
- Induction of functional gonadal somatic cells from mouse embryonic stem cells (mESCs) by a precise differentiation process in culture was demonstrated. For this purpose, mESCs were differentiated into fetal ovarian somatic–like cells (FOSLCs), which were then aggregated with mESCs-derived primordial germ–like cells (PGCLCs), which in turn underwent meiosis followed by oocyte growth, which developed into follicles capable of fertilization with further birth of viable progeny.
Conception raised $20 million for its endeavors in a series A round held in late November 2021.
At the initial stage, Conception is attempting to be the first in the world to create an egg from the blood cells of female donors. If gametogenesis in vitro proves successful, it will destroy all existing rules of reproduction. Women deprived of their ovaries for any reason, such as because of cancer or surgery, will have the opportunity to have biologically related children. Artificial eggs would also remove age restrictions on female fertility, allowing women to have their own children at absolutely any age, even at 50 or 60.
Much more serious and ethically questionable is the prospect of raising hundreds or thousands of artificial eggs that, when fertilized en masse in vitro, would then undergo a selection process to screen out genetic breakdowns that could potentially lead to the development of serious diseases or increase such a risk. It is possible that the eggs will be put through genetic engineering, for example using CRISPR gene editing technology.
Matt Krisiloff, co-founder of Conception, has special views on the success of his venture. Matt is gay, and therefore is very interested in pursuing the idea that two men can have a child genetically related to both partners. Nowadays, children of same-sex male couples are born either by adoption or with a woman willing to conceive a child, either naturally or by surrogacy. In the latter case, the genetic material is transferred only from one of the gay men in the couple. However, it will be a long time before the practical realization of the idea — the transformation of a male somatic cell into a female germ cell.
Biotech startup Ivy Natal, which appeared in April 2020 and has so far raised $250,000 in two rounds of financing, is also trying its hand with gametogenesis in vitro.
Ivy Natal is exploring the possibility of directly reprogramming human skin cells into oocytes, bypassing the intermediate stage of induced pluripotent stem cells (iPSCs). For this purpose, it uses a machine learning system that predicts which transcription factors and their combinations will provide the desired.
Biotech startup Gameto, which focuses on women’s reproductive longevity, held a series A round in January 2022 that raised $20 million.
The venture raised $3 million in the seed round in March 2020. Investors believed in Gameto’s promising ideas to combat accelerated ageing of the ovaries, reflected by menopause and infertility.
Gameto’s plans include synchronizing the rate of ageing of the ovaries with the rate of ageing of other organs such as the liver, brain, or skin. To do this, Gameto is working with a research team at Harvard University to reprogram various ovarian cells, including oocyte precursors and granulosa cells, in pursuit of the goals of the following three research programs addressing major menopausal issues:
- Fertilo. Improving assisted reproductive technology (ART) to eliminate infertility.
- Oocytes that have not matured by the time of retrieval are usually discarded, and existing methods of in vitro fertilization (IVF) are ineffective, which limits the number of oocytes available for IVF. It has been proposed to co-culture steroidogenic granulosa cells (GCs) derived from human induced pluripotent stem cells (iPSCs) and immature oocytes in order to accelerate maturation of the latter in vitro. This will reduce the dose of follicle-stimulating hormone (FSH) during oocyte retrieval and improve oocyte quality.
- DeOvo. Drug discovery based on a model of the female reproductive system.
- A high-throughput screening platform based on the ovaroid system that addresses primary cells and stem cell–derived reproductive cell types and that pursues the goals of modeling fetal and adult ovarian function.
- Ameno. Getting rid of the medical burden of menopause.
- A method has been developed to turn iPSCs into ovarian steroidogenic and support cell types, subsequently placed in a matrix scaffold and delivered to the body as a noninvasive removable implant. These cells restore hormonal homeostasis, delaying or alleviating the symptoms and risks associated with menopause.
The basis of Gameto’s endeavors is a Harvard strategy involving the creation of large databases of transcription factors as signals that determine what a stem cell will eventually become. If only the right factors are rationally activated in iPSCs, their differentiation will occur dozens of times faster than using traditional methods of cell engineering. Thus, iPSCs were transformed into neurons, fibroblasts, oligodendrocytes, and vascular endothelial–like cells with molecular and functional similarity to the primary cells in just 4 days.
Segova Biotechnology, a Serbian company specializing in infertility treatment and increasing the chances of getting pregnant, is pursuing the idea of ovarian rejuvenation as a procedure to restore female fertility using the body’s own (autologous) biological materials.
According to Segova, the oldest woman who has successfully conceived using ovarian rejuvenation is 58 years old.
- The doctrine of reproductive biology postulated that female mammals are born with a finite and non-renewable pool of germ cells. All germ cells in the ovary (oocytes) form at the embryonic stage and are enclosed within somatic cells (granulosa cells) fulfilling an endocrine function, forming primordial follicles. Oocytes that have arrested at the prophase I of meiosis (the so-called dictyate or dictyotene) resume meiosis when it is time to ovulate.      The number of oocytes decreases throughout postnatal life    through mechanisms that include apoptosis.   Eventually, the ovaries are left without germ cells.  In humans, depletion of the oocyte reserve occurs around the fifth decade of life, leading to menopause. 
- However, in 2004 the opposite was proved: rare oogonial stem cells (OSCs), also called female germinal stem cells (FGSCs), were found in postnatal mammalian ovaries.   These undifferentiated OSCs/FGSCs are able to differentiate and form oocytes or eggs  — similar to the spermatogonial stem cells (SSCs) that support sperm production in the adult testes. The discovery refuted the widespread opinion about the limited ovarian reserve, thus opening up new possibilities for treating infertility.  
Segova’s comprehensive 4-day regenerative medicine program for infertility treatment, designed by Aleksandar Ljubić of the University of Dubrovnik (Croatia) and patented (RS P-2020/1329), includes the following four components:
- Stem cell therapy. Autologous mesenchymal stem cells (MSCs), derived from tibial bone marrow cells, are injected into the ovaries, promoting the differentiation of germinal stem cells into healthy follicles. MSCs restore fertility by reducing apoptosis in the stroma and oocytes, inducing folliculogenesis, and improving the ovarian microenvironment.
- Enhancing mitochondrial energy. High-intensity Interval Training (HIIT), as a specific physical exercise regime, increases mitochondrial energy production in ovarian cells.
- Growth factor therapy. Platelet- and leukocyte-rich plasma (PLRP), which is isolated from a patient’s whole blood and then injected into the ovaries, contains concentrated growth factors that play a key role in regulating ovarian function, including controlling growth and production of oocytes and the surrounding ovarian stromal cells responsible for hormonal balance. These factors include growth and differentiation factor 9 (GDF9) and bone morphogenetic protein 15 (BMP15), among others.
- Ovarian in vitro activation. The approach involves taking a biopsy sample of ovarian tissue, its activation in a controlled environment using PLRP growth factors, followed by orthotopic retransplantation. The technique restores gonadal and endocrine function of ovaries depleted due to impaired genetic signaling: Hippo signaling pathway controls organ size, Akt signaling pathway initiates follicular growth.
The NCT04009473 phase 1/2 (non-randomized, open-label, multicenter, international) clinical trial conducted in clinical centers in Malta, Northern Macedonia, and Serbia confirmed the therapeutic efficacy of the minimally invasive Segova ovarian rejuvenation protocol aimed at regaining the hormonal function in women, activating dormant follicles, promotion of antral follicle growth and their development to mature oocytes.
According to data from a sample of 105 patients (average age 46 years) who underwent Segova’s ovarian rejuvenation procedure between 2015 and 2020 and were followed up for two years, positive results of infertility treatment were noted in 61%, as far as the proportion of patients in whom follicles were detected is concerned. However, further results (oocyte aspiration, fertilization, embryo transfer, embryo vitrification, pregnancy) directly depended on many factors, including the overall health of the woman. As a result, live births were recorded in 4 women, which was 6.25% of those who responded to infertility treatment.
- By comparison, the average success rate for in vitro fertilization (IVF) in the United States in 2019 was 4.3% of live births in women over 42 years of age with non-donor eggs.
The biotech startup JumpStart Fertility aims to improve eggs health and restore fertility.
JumpStart’s know-how is based on the hypothesis that reproductive ageing, being an irreversible process, is associated with a decrease in oocyte quality as a factor limiting fertility. Experiments on aged mice showed that administration of nicotinamide mononucleotide (NMN), a metabolic precursor of the oxidized form of nicotinamide adenine dinucleotide (NAD+), leads to improved oocyte quality with subsequent restoration of fertility and rescue of female reproductive function. The benefits of NMN also extend to the developing embryo, reversing the negative effects of maternal age on its developmental performance.
JumpStart is one of many subsidiaries of Life Biosciences, which is fully immersed in body rejuvenation and longevity by focusing on specific aspects of preventing ageing.
- JumpStart, which raised $500,000 in a July 2017 seed round, closed in 2022.
The British-based ProFaM has taken a more traditional route, involving the cryopreservation of ovarian tissue. Subsequently, the preserved tissue is transplanted back, which is in demand when there is a need either to obtain eggs for conception or to delay the onset of menopause. It is claimed that the approach, which is an alternative to standard hormone replacement therapy, will preserve a woman’s health and well-being in pre-menopause for another 10–20 years.
ProFaM’s proprietary technology, which is characterized by the lowest possible surgical risk of ovarian dysfunction, addresses laparoscopic retrieval of the desired material in the form of one-third or one-second of the outer layer of one of the ovaries and without the use of excessive diathermy.
The ovarian transplant is said to remain viable for 5–10 years after transplantation, all depending on its size and quality. If the graft is close to the fallopian tube, there is about a 40% chance of achieving a desirable pregnancy, either naturally or through in vitro fertilization (IVF).
The startup Alife Health has adopted an idea that literally lies on the surface and is obvious to anyone who has encountered or worked with big data. What if we bring in an artificial intelligence that, by operating on large amounts of accumulated data and identifying patterns, could make informed recommendations during in vitro fertilization (IVF) treatments to increase the chances of a successful pregnancy?
The information and analytical tools developed by Alife inform physicians and patients about which IVF methods have proven most effective for others with similar medical and demographic characteristics.
Thus, Alife has developed the Stim Assist computer model, which predicts the most favorable time for a trigger injection. The model has been demonstrated to help physicians retrieve more mature oocytes (eggs) by an average of two to three, more fertilized oocytes (sperm-fertilized eggs) by two, and more viable blastocysts (embryos) by one.
- The goal of controlled ovarian hyperstimulation in IVF cycles is superovulation — ovulation of more mature follicles than usual. During stimulation, the doctor makes a number of decisions that affect the outcome of the cycle: for example, which protocol to use and what initial doses of gonadotropins to administer. One of the most important decisions is when to give the last trigger injection to induce final follicle maturation. Triggering too early will not allow the oocytes to reach maturity, whereas triggering too late will result in postmature oocytes and increase the risk of ovarian hyperstimulation syndrome (OHSS). The optimal timing of a trigger injection is a purely subjective decision and varies widely depending on physicians’ practice and experience, and data supporting any strict objective criteria are limited.
- The prototype machine learning model tested by Alife relies on retrospective data from 30,300 IVF cycles performed in the United States between 2014 and 2020, and considers multiple patient parameters, including age, body mass index (BMI), number of previous IVF cycles, number of antral follicles, levels of anti-Müllerian hormone and estrogen, menstrual cycle length, and follicle size. Remarkably, this model, unlike other similar ones, is able to provide an explanation as to why this or that decision was made.
Alife has developed the Embryo Predict embryo analysis tool, which determines their optimal order for transfer into the uterus. According to preliminary and limited data, the computer ranking of embryos improves the success rate of a pregnancy by 5%–12% when it comes to the set task of selecting the most viable embryos.
- In IVF, mature eggs are collected and fertilized with sperm in the lab to create embryos. The embryologist manually evaluates and selects the embryo cultured to the blastocyst stage in terms of priority for transfer to the uterus based on genetic testing (check for autoploidy) and a morphological grading system (reflecting the degree of blastocyst expansion and quality of the inner cell mass and trophectoderm). This process, being subjective and biased, is not unified in any way.
- A pilot generalizable deep learning model validated by Alife relies on retrospective images and associated metadata from 8,500 embryos (at the blastocyst stage) obtained during IVF in the United States between 2015 and 2020.
In the long term, Alife hopes its technology will reduce the high cost of IVF by making it more affordable by reducing the number of cycles performed. In the U.S. one IVF cycle together with the necessary medications costs up to $25,000. Usually there are several IVF cycles and health insurance doesn’t always cover them.
The venture capital investment in Alife, launched in May 2021, was $31.5 million.