Autophagy in ovary: protective roles, pathological consequences, and unresolved issues

Abstract

The ovaries play essential roles in providing oocytes for fertilization and secreting sex hormones that regulate various organ functions. Autophagy has been implicated in the modulation of ovarian functions, yet its mechanisms of action are complex and context-dependent. Within the ovary, autophagy fulfills a dual function, serving as a critical mechanism in facilitating oocyte development, maintaining granulosa cell viability, regulating hormone synthesis, ovulation and luteal function. Conversely, dysregulation of autophagy can interact with other death signals, leading to cell death of ovarian cells, and has been linked to the development of diminished ovarian reserve (DOR), premature ovarian insufficiency (POI) and polycystic ovary syndrome (PCOS). Emerging evidence suggests that pharmacological modulation of autophagy exerts significant therapeutic effects on POI and PCOS. Despite this association, numerous unresolved issues persist in this field of research. This paper provides a comprehensive overview of the context-dependent roles of autophagy in ovarian physiology and disorders, and proposes potential applications of autophagy-based interventions as therapeutic strategies for addressing ovarian dysfunctions.

Introduction

The primary functions of ovary are to produce oocytes for reproduction and to secrete hormones for systemic regulation. Ovarian dysfunction profoundly compromises female health, impairing fertility, sexual well-being, skeletal integrity, cardiovascular function, and cognition [1]. Mounting evidence implicates dysregulated autophagy as a pivotal mechanism underlying such pathologies.

Autophagy constitutes an evolutionarily conserved self-degradative mechanism essential for cellular homeostasis, wherein cytoplasmic components are delivered to lysosomes for recycling. This catabolic process critically maintains metabolic equilibrium through selective elimination of damaged organelles (e.g., mitophagy) and non-selective bulk degradation, particularly under stress conditions [2–4]. Macroautophagy—the predominant autophagic pathway involving double-membraned autophagosomes that fuse with lysosomes—serves as a fundamental cytoprotective response against nutrient deprivation, proteotoxic stress, and pathogenic invasion [5, 6]. Core molecular machinery including LC3 (autophagosome biogenesis marker), SQSTM1/p62 (autophagy receptor), Beclin1 (autophagy initiation complex component), and autophagy-related genes (ATG) collectively orchestrate this dynamic process, rendering autophagy indispensable for cellular integrity and organismal health [7].

Autophagy critically governs ovarian homeostasis and pathophysiology. Under physiological conditions, it safeguards follicular integrity by maintaining viability of ovarian compartments [8]. Paradoxically, excessive or dysregulated autophagy can trigger oocyte and granulosa cell (GC) death, contributing to conditions like premature ovarian failure (POI) and polycystic ovary syndrome (PCOS), underscoring its context-dependent duality [9]. Recent evidence shows that specialized autophagic pathways, such as lipophagy (providing lipid substrates for steroidogenesis in luteinized GCs) and ferritinophagy (regulating ovarian iron homeostasis), further modulate ovarian function[10–12]. Despite these advances, the multifaceted roles of autophagy and its crosstalk with other cell death pathways in regulating ovarian functions and driving non-neoplastic ovarian disorders remain incompletely characterized, with many unresolved issues persisting.

This review summarizes current knowledge on the context-dependent functions of autophagy in normal ovarian physiology and the pathogenesis of POI and PCOS. We further evaluate emerging evidence on autophagy modulation as a therapeutic strategy for ovarian dysfunction, aiming to inform future translational research.

Autophagy in ovarian physiology

Autophagy in oocytes development and quality control

Autophagy dynamically regulates mammalian oocyte maturation within ovarian follicles, fine-tuning the microenvironment essential for gamete competence. Key autophagic proteins exhibit stage-specific expression: ATG9 localizes in murine germinal vesicle (GV) and metaphase II oocytes [13], while ATG4C declines in porcine oocytes during metaphase I [14]. Temporal profiling reveals autophagic flux in porcine cumulus-oocyte complexes (COCs) peaks at 14 h and wanes by 42 h [15]. Transcriptomic analyses based on single-cell transcriptomic sequencing along with online RNA-sequencing data associate downregulated autophagosome-assembly genes with oocyte atresia in sheep [16].

During early post-ovulatory oocyte aging (POA), autophagy is triggered as an adaptive defense mechanism against apoptosis [17]. Conditional knockdown of Beclin1 in oocytes impairs first polar body extrusion, compromises mitochondrial function, activates DNA damage response, and induces early apoptosis [18]. Pharmacological activation of autophagy via rapamycin enhances oocyte developmental capacity, whereas lysosomal inhibition by chloroquine disrupts chromosome alignment, cytoskeleton organization and subsequent embryonic development [19, 20]. Notably, oocytes from medium follicles exhibit greater sensitivity to autophagy modulators (3-MA and rapamycin) than those from small follicles, indicating size-dependent manner of autophagic regulation in oocyte competence [21]. As reviewed by Shen, mitophagy in oocytes, though not constitutively active, supports oocyte development and is inducible by specific stimuli [22]. Recent studies on regulators of oocyte competence frequently operate through autophagy/mitophagy modulation[23–30]. For example, phospholipase D1 promotes microtubule-organizing center clustering, spindle assembly and cortical migration by maintaining physiological levels of actin related protein 2, phosphatidylinositol 4,5-bisphosphate and phosphorylated-cofilin 1 through modulating their autophagic-dependent degradation [28]. Autophagy dysregulation further contributes to compromised oocyte quality in advanced maternal age [31] (Fig. 1A). An age-related decline in mitophagy was initially identified in murine oocytes, evidenced by accumulated RBR E3 ubiquitin protein ligase and diminished RAS GTPase family member 7 (RAD7) levels of aged oocytes [32]. Peters et al., subsequently confirmed autophagy impairment and lysosomal dysfunction in aged oocytes [33]. Notably, while lysosomal and mitochondrial functions are compromised in aging murine oocytes, compensatory activation of mitophagy and ferritinophagy may occur, the latter potentially sequestering newly synthesized ferritin heavy chain protein [10]. Therapeutic intervention using RAB7 activator, or deferoxamine rescues oocyte developmental parameters by restoring protective mitophagy, ferritinophagy, respectively [10, 32]. Similarly, supplementation with insulin-like growth factor 2, or metformin enhances oocyte quality through autophagy potentiation [34, 35]. Collectively, these findings establish that rectifying physiological autophagy/mitophagy levels in oocytes may work as promising approach of rescuing their quality deficits (Fig. 1A).

Fig. 1.

Autophagy in ovarian cells. The dual regulatory roles and unsolved problems of autophagy in oocytes, granulosa cells (GCs), and theca-interstitial cells (TICs) are summarized in boxes A, B, C

Beyond sustaining oocyte quality, aberrant autophagy/mitophagy frequently contribute to stimulus-induced oocyte injury [36–43] (Fig. 1A). In such contexts, autophagy typically coexists with or precedes apoptosis [44–48]. Autophagy/mitophagy still exert exceptional protective effects. A recent mechanistic study revealed that GV stage oocytes in aging mice and pigs fail to activate autophagy upon moderate DNA damage, causing chromatin misalignment, impaired recruitment of checkpoint protein and subsequent localization to damage sites, and consequent aneuploidy accumulation. Therefore, chronologically aged oocytes exhibit persistent autophagic dysregulation, compromising DNA damage repair capacity and accumulated DNA damage. Critically, pharmacologically induced autophagy in aged oocytes ameliorates DNA damage and restores DNA damage repair response [48]. Pharmacological studies confirm context-dependent duality in autophagy regulation of oocyte competence across ovarian microenvironments [30, 49–61]. Metabolomic profiling identified diminished ovarian spermidine in aged mice. Spermidine supplementation restored aged oocyte competence through mitophagy enhancement, a mechanism conserved in porcine models [61]. Conversely, limonin (a tetracyclic triterpenoid from citrus/traditional Chinese medicine) promotes bovine oocyte maturation in vitro by suppressing excessive autophagy and apoptosis [52].

Autophagy thus exhibits stage-, stimulus- and compartment-specific regulation of oocyte fitness: Physiological activity preserves developmental competence and possesses environmental adaptation, whereas deficiency or excess exacerbates damage alongside concomitant death signals. Consequently, precisely timed remodeling physiological autophagy represents a promising therapeutic strategy for oocyte quality preservation. Future studies should delineate its spatiotemporal dynamics to optimize clinical translation.

Autophagy in granulosa cell viability and steroidogenesis

GCs constitute essential somatic support for oocyte development, with autophagic activity critically influencing oocyte competence and ovarian homeostasis. Aged human GCs exhibit diminished autophagy coincident with attenuated citrate metabolism. Notably, citrate in follicular fluid promotes porcine oocyte quality [62] (Fig. 1B). A recent study report age-associated downregulation of cryptochrome 1 (Cry1) and increased ferritinophagy in GCs [63]. Transcriptomic profiling of Cry1-depleted KGN cells reveals enhanced senescence, ferroptosis, and autophagic activity. Mechanistically, Cry1 modulates HECT and RLD domain-containing E3 ubiquitin ligase 2 expression to regulate ubiquitination and degradation of nuclear receptor coactivator 4 (NCOA4), thereby impairing NCOA4-mediated autophagy and promoting senescence [63].

Autophagy plays a crucial role in maintaining homeostasis and viability within GCs. Previous studies utilizing siRNA-mediated knockdown of ATG5, Beclin1 and pharmacological autophagic inhibitors demonstrated that autophagy facilitates GC differentiation by degrading WT1, thereby coordinating development of ovarian somatic cells [64]. Consistently, Zhu et al., reported that autophagy ensures GC responsiveness to gonadotropins by undergoing follicle-stimulating hormone (FSH)-induced upregulation in antral follicles GCs and facilitating WT1 protein degradation [65] (Fig. 1B). Notably, autophagy exerts context-dependent effects on GCs. Overexpression of ATG7 in porcine GCs induces excessive autophagosome accumulation and subsequent apoptosis [44]. Accumulating evidence indicates that autophagy and mitophagy dynamically regulate GC function, influenced by specific physiological or pathological conditions [66–88] (Fig. 1B). Dysregulated hyperactivation of autophagy frequently exhibits cytotoxicity, interacting synergistically with apoptotic and ferroptosis pathways to compromise GC survival [68–79, 89–106]. Conversely, basal or moderately induced autophagy promotes GC viability under certain circumstances [80–88, 107–112] (Fig. 1B). Intriguingly, POI models reveal cell-type-specific autophagy responses: elevated autophagy occurs in SVOG GCs, whereas KGN GCs exhibit significant autophagy downregulation [113, 114].

In ovarian steroidogenesis, the role of autophagy appears complex and depends on experimental settings. The secretion of ovarian hormones as well as estrogen signaling have been previously shown to be directly or indirectly modulated by autophagy. In GCs of patients diagnosed with ovarian endometriosis, upregulated Beclin1 was associated with increased progesterone (P4) biosynthesis, Beclin1 knockdown reduced P4 secretion and downregulated key steroidogenic enzymes of GCs [115]. Conditional knockout of Beclin1 in ovarian luteal cells prohibited lipid storage and reduced P4 and estradiol (E₂) level in mice during mid-pregnancy [116, 117]. Likewise, a significant decrease in E₂ secretion of murine GCs and KGNs after autophagic inhibition was observed in Shao’s in vitro study [64]. In porcine GCs, exogenous FSH administration upregulated autophagy and promoted P4 biosynthesis, which could be counteracted by autophagic inhibitor chloroquine [118, 119]. Autophagy-mediated degradation of estrogen receptor α might influence the physiological effects of E₂ signaling [120]. Lipophagy, known as a specialized form of autophagy regulating lipid metabolism, responsible for delivering lipid droplet to lysosome and releasing free cholesterol required for steroidogenesis [11, 12]. Studies delineating the regulators of GCs also proved the negative effects of autophagy on ovarian steroidogenesis. For example, bisphenol A (BPA)-induced disruption of estrous cycle and estrogen secretion involves activation of GC autophagy [99]. (Fig. 1B).

Autophagy in oocytes-GCs communications

Autophagy critically mediates bidirectional communication between oocytes and GCs, a process essential for follicular development [121]. GCs engulf apoptotic oocytes through unconventional autophagy-assisted phagocytic mechanisms involving autophagy molecules LC3 and Beclin1 [122]. Selective autophagy in GCs regulates citrate metabolism to influence oocyte competence and fertilization outcomes [62], this underpins the utility of monitoring GC autophagy as a biomarker for predicting oocyte maturation efficiency [123].

Mitophagy serves as a key metabolic conduit in oocyte-GC crosstalk. Environmental stressors primarily activate mitophagy in GCs, which subsequently modulates mitochondrial homeostasis in both cell types [22, 124]. Clinical evidence demonstrates that enhanced mitophagy in cumulus cells correlates with improved oocyte retrieval rates, fertilization rates, and pregnancy outcomes after dehydroisoandrosterone (DHEA) treatment in poor responders [124]. Notably, oocyte mitophagy requires specific triggers, whereas GC mitophagy routinely compensates for follicular stress [125]. Ferritinophagy has also been proposed to mediate this interplay, as iron-overloaded follicular fluid in endometriosis patients induces ferroptosis-associated ferritinophagy in GCs, which subsequently exacerbates oocyte quality impairment [126].

The autophagy-stress response between oocytes and GCs exhibits dual regulation: Moderate ROS induces protective autophagy in both cell types, but severe oxidative damage triggers autophagic GC death. This depletes oocyte nutrients, activating compensatory autophagy pathways [123]. Collectively, both non-selective autophagy and selective pathways in GCs constitute the primary defense barrier, integrating nutrient sensing and quality control within the follicular microenvironment.

Autophagy in theca-interstitial cells

Emerging evidence implicates autophagy in ovarian theca-interstitial cells (TICs), though less characterized than in GCs. Immunohistochemical analyses of human ovaries reveal Beclin1 enrichment in the theca layers of developing follicles, with post-ovulatory persistence in theca-lutein and granulosa-lutein regions [127], suggesting potential roles of autophagy in luteal function and androgen production. Pathologically, cisplatin-induced POI models demonstrate significant upregulation of autophagy in TICs, indicating stress-responsive involvement [128] (Fig. 1C).

Autophagy in primordial follicle pool formation

Autophagy critically regulates primordial follicle pool formation through spatiotemporal modulation of germ cell dynamics. During fetal ovarian development, it sustains germline viability via catabolic recycling during oocyte cyst breakdown [129, 130], and facilitates nutrient adaptation upon the fetal-to-neonatal transition by supplying surviving oocytes with essential metabolites [131, 132]. Neonatal starvation studies further confirm its beneficial role in mammal primordial follicle pool expansion [131, 132]. Maintaining appropriate autophagy levels is imperative, as both deficiency and excess compromise germ cell integrity and disrupt primordial follicular pool formation [8, 133]. This balance is intricately manipulated by diverse regulators – for instance, AMH triggers compensatory autophagy through FOXO3 phosphorylation during follicular depletion [134]. Genetic models unequivocally establish autophagy’s essential role in primordial follicle preservation. Neonatal ATG7^−/− ovaries exhibit severe germ cell depletion and structural abnormality, while Beclin1 heterozygous knockout mice demonstrate significant primordial follicle reduction. Conversely, this pathway exerts detrimental effects in specific ovarian contexts. In vitro culture models reveal autophagy activation mediates primordial follicle depletion [135], cathepsin B-dependent machinery sustains ovarian reserve through dual suppression of apoptosis and autophagy pathway [136]. Perinatally, heightened autophagy activity is observed in ovaries harboring nascent oocytes. Critically, inhibiting autophagy prior to primordial follicle pool assembly increases cystic oocyte numbers and retards folliculogenesis [137, 138]. Recent studies have elucidated regulatory networks that fine-tune this balance: lysine-specific demethylase 1 suppresses autophagy to prevent oocyte attrition, whereas impaired autophagic flux compromises ovarian reserve in sirtuin 1-deficient and cystine/glutamate transporter-dysregulated models [137, 139–142].

Autophagy in follicular development

Autophagy exerts context-dependent regulation throughout follicular development, serving as a critical stress-adaptation mechanism (Fig. 2B). Multi-omics analyses reveal dynamically changed autophagy during follicular development: proteomic profiling demonstrates decreased apoptosis and increased autophagy signatures from neonatal to prepubertal murine ovaries [136], while RNA-sequencing data indicated differently-expressed circular RNA of varying follicular diameters correlates with autophagy pathways in ewe [143]. Genetic and pharmacological evidence repeatedly confirms its functional significance in follicular development: IL-33 knockout mice exhibit accelerated ovarian aging with concomitant autophagic suppression [144], chloroquine antagonizes the follicular development in response to FSH signal [145], and nicotinamide mononucleotide enhances folliculogenesis via autophagy potentiation in aging models [146].

Fig. 2.

The regulatory effect of autophagy on follicular units. A The upper box depicts the role of autophagy in the physiological (right) and pathological (left) modulation of the primordial follicle pool. B The middle box presents the regulatory effects of autophagy on follicular development and atresia. C The lower box summarizes the roles of autophagy in regulating ovulation and luteal function. Specifically, the positive regulatory roles of autophagy are emphasized in pink boxes, while its negative regulatory roles are highlighted in grey boxes. Upward arrows signify elevation, downward arrows denote reduction, and circles with an inner plus or minus sign represent promotion or inhibition respectively. The unconventional role of autophagy in follicular atresia is listed in blue boxes. Aut: autophagy; AMH: anti-Müllerian hormone; F: follicle; FETophagy: ferritinophagy; lncRNA: long noncoding RNA; Patho: pathological; Physio: physiological; PrF: primordial follicle

Autophagy serves as a dual regulator of follicular homeostasis (Fig. 2B). Specifically, voltage-dependent anion channel 2 facilitates primary-to-secondary follicle transition by suppressing autophagy [147], whereas genetic ablation of oocyte-specific casein kinase 1α compromises follicular development through enhanced autophagic activity [148]. Tumor necrosis factor-α modulates ovulation and GC viability via concurrent induction of autophagy and apoptosis [149], and ovarian auto-transplantation models demonstrated upregulated autophagy initiates follicular activation [66].

Autophagy in follicular atresia

Autophagy serves as an evolutionarily conserved regulator of follicular atresia across mammalian species. In rodent models, autophagy functions as both an oocyte death pathway and an upstream initiator of GC apoptosis. Primordial follicle atresia in spiny mice occurs predominantly through autophagy [150], and prepubertal rats execute germ cell elimination via autophagic cell death [151–154]. Porcine studies reveal follicular size- and species-dependent regulation by autophagy, where GCs in follicles (2–6 mm diameter) undergo autophagy-mediated degeneration GCs, and follicular atresia in normal-sized pigs typically occurs in an autophagic pattern [155, 156]. Recent evidence further confirmed autophagy was involved in ovine follicular regression [157]. Although GC apoptosis represents the predominant mechanism of late-stage mammalian follicular atresia, this process is crucially linked to autophagic hyperactivation mediated by specific signaling molecules including miRNA let-7 g and transcription factor CREBZF [158, 159].

Emerging evidence highlights autophagy’s non-canonical role in follicular homeostasis. In Lagostomus maximus, it clears degenerated follicles and corpora lutea to accommodate multi-follicular development required for high fecundity [160]. In vitro studies demonstrate unconventional autophagic machinery (ATG5/Beclin1/LC3II) mediates cellular waste clearance in GCs [122]. These data indicates that autophagy functions as a self-cleaning system beyond conventional cell death paradigms (Fig. 2B).

These findings collectively demonstrate that autophagy orchestrates primordial follicle pool formation, physiological follicular development and atresia, through intricate crosstalk with regulatory signals (Fig. 2 A, B). Under physiological conditions, it serves as an essential nutrient adaptation mechanism for cellular macromolecule recycling. When suffering stress, protective autophagy requires precise containment to prevent cytotoxic outcomes. The molecular determinants of protective or detrimental autophagy responses in follicles remain to be dissected in future studies.

Autophagy in maintenance of ovulation and luteal function

Autophagy critically regulates ovulation and luteal dynamics (Fig. 2C). Pharmacological inhibition of autophagy flux via chloroquine leads to anovulation in murine models [161]. Transcriptomic profiling of porcine ovaries upon protein-coding genes and long intergenic non-coding RNAs reveals cyclic expression of autophagy-related gene from estrus to diestrus, implicating autophagy in ovulation/luteal functionality regulation [162]. During post-ovulatory luteolysis, autophagy promotes ovarian cyclicity through metabolite clearance, evidenced by abundant autophagosomes and upregulated autophagic pathways [163, 164]. Paradoxically, controlled Beclin1 extends pregnant corpus luteum (CL) persistence under pathological conditions, highlighting autophagy’s dual roles in CL lifespan regulation [165]. Emerging evidence further delineates this paradigm: suggesting ferroptosis and ferritinophagy as additional drivers of CL regression during parturition [166].

Signals pathways linking autophagy and ovarian function

Key upstream regulators of ovarian autophagy include the adenosine monophosphate-activated protein kinase (AMPK)/mechanistic target of rapamycin (mTOR), the phosphoinositide 3-kinase (PI3K)/serine-threonine kinase B (AKT), and forkhead box O3A (FOXO3A). The energy sensor AMPK activates autophagy via phosphorylation-dependent mechanisms [167]. mTOR serves as a central cellular regulator, with its canonical substrates S6K1 directly governing autophagy. Additional mTOR substrates including AKT, serum/glucocorticoid-regulated kinase 1, and protein kinase C, may also modulate autophagy [168]. PI3K is a primary mTOR effector, initiating signaling cascades that significantly influence autophagy [169]. In oocytes, PI3K activation triggers a specific phosphorylation cascade essential for follicular growth, concurrently resulting in phosphorylation and cytoplasmic translocation of the transcription factor FOXO3A [170].

Accumulating evidence implicates dysregulation of these signal pathways in ovarian aging and injury. For example, adipose-derived stem cell exosomes alleviate ovarian damage by suppressing autophagy via AMPK/mTOR pathway inhibition [77]. Similarly, human umbilical cord mesenchymal stem cells-derived small extracellular vesicles (huMSC-sEVs) improved ovarian reserve in cisplatin-induced POI rats through PI3K/Akt pathway activation and autophagy perturbation [169]. Anti-Müllerian hormone (AMH) preserves ovarian reserve through FOXO3A-mediated autophagy induction [134, 170].

Crosstalk between autophagy and cell death pathways in the ovary

Emerging evidence delineates autophagy as a critical determinant of cellular fate, prompting the classification of cell death pathways into autophagy-dependent cell death (ADCD; e.g., ER-phagy, mitophagy, autosis) and autophagy-mediated cell death (AMCD; e.g., apoptosis, necrosis, ferroptosis, wherein autophagy serves as an upstream modulator or trigger) [171–173].

Apoptosis, the most extensively characterized form of AMCD, displays complex bidirectional crosstalk with autophagy, encompassing circumstances wherein autophagy may suppress apoptosis, or promote apoptosis (via direct binding to apoptotic regulators or engulfment of apoptotic components), or operates in parallel without functional interplay[171, 174–176]. In ovarian contexts, co-activation of both pathways frequently occurs under shared regulatory signals or physiological stressors such as excessive oxidative stress, irreversible apoptosis may ensue when protective autophagy is overwhelmed during severe ovarian injury [39, 58].

Ferroptosis represents a well-defined AMCD process governing cellular iron flux, redox homeostasis, and lipid metabolism [177–179]. Key mechanisms include NCOA4-mediated ferritinophagy and degradation of ferritin and iron-export proteins by mitophagy [179–183]. Pathological ovaries frequently exhibit concurrent ferroptosis, mitophagy, and ferritinophagy, fueled by iron dysregulation and mitochondrial dysfunction. Critically, these pathways may engage in dynamically reinforced feedback loops that exacerbate ovarian aging and injury [10, 166, 184, 185].

Autophagy in non-tumorous ovarian pathology

Autophagy in diminished ovarian reserve

Diminished ovarian reserve (DOR), a condition marked by reduced antral follicle count, low AMH, and elevated FSH, could be physiological aging in women over 45 years but signifies a pathological state in younger individuals [186]. Accumulating evidence implicates dysregulated autophagy and mitophagy in ovarian aging. Studies of age-related ovarian decline reveal impaired mitophagy and autophagy, characterized by reduced Nur77 expression (murine models) and elevated Rubicon levels (human tissue), activation of autophagy or mitophagy pathways in the above models decelerates ovarian aging [187, 188]. Notably, next-generation sequencing of 120 patients with idiopathic pathological DOR identified deleterious mutations in genes governing autophagy, mitochondrial metabolism, folliculogenesis, DNA repair/meiosis, aging, and ovarian development, suggesting a multifactorial genetic basis for DOR pathogenesis [189].

Experimental models and clinical samples further underscore autophagy dysregulation in DOR. Contrasting findings exist regarding mitophagy activation: While the 4-vinylcyclohexene diepoxide-induced DOR model exhibits activated ovarian mitophagy, and its suppression paradoxically preserves function in rats [190, 191]. Studies in human GCs indicate overactivated autophagy associated with DOR. Zhang et al., reported significantly decreased expression of the long non-coding RNA Prader-Willi region non-protein coding RNA 1(PWRN1) in GCs from DOR patients. PWRN1 downregulation promoted apoptosis and autophagy in KGN and impaired ovarian function in mice, positioning it as a potential regulator [192]. Similarly, Li et al., observed elevated estrogen receptor beta expression and intensified autophagy in GCs from DOR patients [191].

Clinically, poor ovarian response (POR), a condition with decreased retrieved oocyte numbers and low E₂ levels in response to ovarian stimulation, often heralds DOR and shares its underlying pathophysiology [193, 194]. Studies consistently demonstrate intensified autophagy or mitophagy in cumulus cells of POR patients [124, 195]. A recent study has implicated dysregulated expression of autophagy receptor P62 in human GCs as a potential contributor to POR pathogenesis. Mechanistically, GC-specific knockout of p62 resulted in impaired autophagic flux, reduced ubiquitinated protein clearance, and accumulation of non-ubiquitinated WT1 protein, thereby disrupting GC biological functions including differentiation, steroidogenesis and gonadotrophin responsiveness [196]. Collectively, these findings strongly implicate dysregulated autophagy and mitophagy across the spectrum of DOR and its clinical manifestation including physical aging and POR, as vital mechanisms driving ovarian dysfunction and follicular depletion.

Autophagy in POI

POI, affecting approximately 1% of women, is defined by the loss of ovarian function before age 40. Key clinical features include amenorrhea or oligomenorrhea, elevated gonadotropins, and diminished E₂ levels [197]. GCs from biochemical POI patients exhibit autophagy overactivation, potentially mediated by oxidative stress[198]. Genetic evidence increasingly implicates autophagy dysregulation in POI pathogenesis, exemplified by mutations in core autophagy genes ATG7 and ATG9 in idiopathic POI cohorts, positioning compromised autophagy as a significant risk factor [199]. Supporting this, genetically engineered murine models also demonstrate that impaired autophagy correlates with DOR [129, 199, 200]. Notably, EPG-deficient mice5 (lacking a critical mediator of the autophagosome-lysosome fusion) develop POI-like phenotypes featuring impaired WT1 degradation, suppressed steroidogenesis, and disrupted GC differentiation [201].

POI exhibits significant genetic heterogeneity, with emerging evidence identifying ATGs as direct targets of pathogenic variants or critical mediators of pathology [26, 29, 202–208]. For example, a bioinformatic analysis based on bulk sequencing data of GCs from clinical samples discovers cytoskeleton-associated protein 5 (CKAP5) as a candidate gene of POI, and validates CKAP5 upregulates autophagy via interacting with ATG7, a CKAP5 variant in POI females is also identified by the same group [202]. Member RAS oncogene family 37 (Rab37) was recently marked as a vital regulator of autophagy, ovarian development and follicular homeostasis, activation of autophagy mitigated ovarian dysfunction in Rab37 knockout mice by remodeling ovarian homeostasis [204]. Another study uncovered the vital role of protein phosphatase 4 (PPP4C) in regulating primordial follicle pool, oocyte-specific knockout of PPP4C led to exhausted ovarian reserve and POI, which involves mTOR overactivation and autophagy inhibition, of note, the degenerated oocytes could be erased by autolysosomes of pregranulosa cells [26]. Accumulating evidence shows that aberrant autophagy mediates multifactorial POI by triggering ovarian cell death and associated pathology (Table 1).

Table 1.

Autophagy in multifactor-induced POI

POI	Human/animal model	Exposed factor	In vivo/ in vitro	Ovarian pathology	Affected cells	Autophagy related gene or protein changes	References
Environmental pollutants-induced POI	Human	BPA	In vivo, in vitro	Decreased oocyte retrieval rate, maturation rate and embryonic implantation rate	GCs	LC3B, Beclin1↑, P62↓	[209]
	Mice	BPA	In vivo, in vitro	Deceased serum levels of E2, P4 and AMH, decreased number of GCs, cystic dilation of the follicles	GCs	LC3B, ATG7, Beclin1↑, P62↓	[99, 209]
		BPS	In vivo	Disrupted early folliculogenesis dynamics and accelerated cyst breakdown, impaired oocyte quality and aggravated oocyte loss, induced precocious puberty, estrus cycle disorder, and fertility reduction	Unknown	Beclin1, LC3-Ⅱ/LC3-Ⅰ, p-ULK1↓, P62, p-mTOR↑	[215]
		TOCP	In vivo, in vitro	Reduced ovarian function and serum E2 levels	GCs	LC3-Ⅱ, P62, Beclin1, ATG5, LC3-Ⅱ/LC3-Ⅰ and cytoplasmic autophagosomes↑	[210]
		DEHP	In vivo, in vitro	Impaired primordial follicle assembly	oocytes	LC3, ATG5, Beclin1, Cathepsin B, LAMP2, LC3-II/LC3-I↑	[211]
		BHPF	In vivo, in vitro	Impaired oocyte maturation and increased atretic follicles	oocytes	LC3, Beclin1, ATG12, ATG14↑	[213]
		DBDPE	In vitro	Disrupted oocyte maturation and fertilization	oocytes	LC3, Beclin1↑, mTOR↓	[214]
		Malathion	In vivo	Disrupted estrous cycle and decreased hormone production	GCs	LC3, ATG5, ATG7, LC3B-II/LC3B-I↑, P62↓	[217]
		Glyphosate	In vivo	Decreased ovarian index, disrupted oocyte maturation	oocytes	LC3, Beclin1, ATG12, LC3-II/LC3-I↑	[219]
		Melamine	In vivo	Decreased ovarian weight, oocyte developmental potential, and offspring numbers	oocytes	LC3↑	[221]
		Methylmercury chloride	In vivo, in vitro	Decreased the ovarian coefficient, impaired reproductive performance, the oocyte maturation ability	oocytes	LC3↑, P62↓	[225]
		Polystyrene nanoplastics	In vivo, in vitro	Reduced oocyte quality and female fertility	GCs	ATG5, Beclin1↑, P62, LC3-Ⅰ/LC3-Ⅱ, PI3K, p-AKT/AKT, mTOR↓	[73]
		Arsenic	In vivo, in vitro	Reduced total follicle numbers, serum AMH levels, gonadotropin responsiveness and oogenesis, increased atresia follicles	GCs	LC3B↑, P62↓	[228]
	Rats	PBDE-47	In vivo	Decreased ovarian index and follicles, increased corpus luteum	oocytes	Beclin1, P62, LC3-Ⅱ/LC3-Ⅰ↑	[216]
		Acrylamide	In vivo	Decreased ovarian weight and serum P4 and E2 levels	GCs	LC3, ATG5, ATG12↑	[222]
		Ethylbenzene	In vivo	Decreased ovarian weight, abnormal follicular development (increased abnormal follicles, decreased primordial and growing follicles), abnormal hormone production (decreased LH levels, increased E2 levels)	GCs	LC3↑	[223]
		Cadmium	In vivo	Reduced ovarian weight, prolonged estrous cycle, increased atretic follicles	GCs	LC3-Ⅱ↑, P62, p-mTOR↓	[224]
		Fumonisin B1	In vivo	Increased ovarian weight index, decreased the number of offspring, the number of primordial follicles in the F1 and F2 female rats	Unkown	LC3↓ in F1, LC3↑ in F2	[229]
	Pigs	Methylmercury chloride	In vitro	Impaired porcine oocyte maturation and cumulus cell expansion	oocytes	Pink1, Parkin, LC3, p-AMPK↑, P62, p-mTOR↓	[225]
Unhealthy lifestyle-induced POI	Human	Underweight	In vitro	Decreased oocyte maturation and fertilization rates	cumulus cells	Atg-5, Lc3-II, Beclin1↑	[72]
	Mice	Obesity	In vitro	Retarded embryonic development	oocytes	autophagic vacuoles↑	[232]
		Cigarette smoke	In vivo	Decreased ovarian index, decreased primordial and growing follicles	GCs	Beclin1, LC3↑	[233, 234]
		Nicotine	In vivo, in vitro	Decreased ovarian weight and reduced ovarian reserve	oocytes	AMPKα−1, LC3-II:LC3-I↑ AKT, mTOR↓	[235]
		Heat stress	In vivo	Decreased P4 levels, disrupted reproductive performance in early pregnant mice	luteinizing cells	LC3, ATG7↑ P62↓	[240]
		Chronic unpredictable mild stress	In vivo	Decreased the count of both primordial follicles and antral follicle	Unknown	LC3B↑	[242]
		Fetal hypoxia	In vivo, in vitro	Damaged ovarian function and oocyte maturation	GCs	ATG7, P62, LC3B, Beclin1↑, p-AKT/AKT↓	[244]
				Decreased plasma FSH, LH, E2, AMH	GCs	ATG5, ATG7, Beclin1, LC 3B↓, P62↑	[245]
	Rats	Malnutrition	In vivo	Decreased ovarian reserve	oocytes	LC3, Beclin1↓	[243]
		Electromagnetic radiation	In vivo	Decreased the number of average primordial and growing follicles	Unknown	Beclin1↑	[241]
	Pig	Heat stress	In vivo	Increased vacuolization of the oocyte and surrounding GCs	oocytes	LC3, Beclin1,LC3-II:LC3-I↑ ATG12-ATG5↓	[238]
	Bovine	Heat stress	In vitro	Reduced the proportion of oocytes that developed to the blastocyst stage	oocytes	LC3-II:LC3-I↑	[239]
				Reduced cleavage rate and blastocyst rate	oocytes	Beclin1,ATG5↑	[40]
Iatrogenic POI	Mice	Cisplatin	In vivo, in vitro	Excessive follicular loss, increased plasma FSH, decreased E2	GCs	ATG12↑, P62↓	[248]
		Cyclophosphamide	In vivo, in vitro	Prolonged diestrus period and decreased serum levels of AMH	GCs	LC3, Beclin1↑, P62↓	[251]
			In vivo	Decreased primordial follicles	Unknown	LC3↓, P62↑	[134]
			In vivo	Decreased ovary weight and size, sinus follicles, GC layer, and corpus luteum, increased atretic follicles	GCs	Beclin1, LC3-II:LC3-I↑	[253]
			In vivo, in vitro	Increased plasma FSH, atresia follicles, decreased E2, primordial follicles, primary follicles, secondary follicles, and mature follicles	GCs	LC3 ↑	[185]
			In vivo, in vitro	Decreased primordial follicles, disrupted follicular development, decreased serum levels of AMH and E2, increased FSH	GCs	Beclin1, LC3-II:LC3-I↑, P62↓	[262]
		Triptolide	In vivo, in vitro	Reduced ovarian weight and retarded oocytes development	oocytes	LC3 ↑	[252]
		Cyclophosphamide and Busulfan	In vivo, in vitro	Increased plasma FSH, decreased AMH	GCs	LC3B, p-P62, PINK 1, PARKIN↓	[83]
			In vivo, in vitro	Decreased the ovarian weight, plasma E2, increased FSH	GCs	LC3-II:LC3-I↑ P62↓	[309]
	Rats	Cisplatin	In vivo, in vitro	Reduced developmental follicles, increased atresia follicles, increased plasma FSH and LH, decreased E2	TICs	AMPK, p-AMPK/AMPK, LC3 II ↑ mTOR, p-mTOR/mTOR↓	[128]
		Triptolide	In vivo, in vitro	Decreased primary follicles and secondary follicles, E2 and AMH, increased atretic follicles, serum levels of FSH and LH	GCs	Beclin-1, LC3-II/LC3-I↑, P62↓	[101]
		Cyclophosphamide	In vivo, in vitro	Lengthened the anoestrum, reduced E2, mature follicles, primordial follicles, and secondary follicles, increased FSH and LH, atresia follicles	GCs	LC3-II/LC3-I↑	[332]
			In vivo, in vitro	Irregular estrous cycle, reduced AMH and E2, increased FSH and LH, increased atretic follicles, decreased primordial and total follicles	GCs	Drp1, Pink1, Parkin↑	[260]

AMH anti-Müllerian hormone, AMPK AMP-activated protein kinase, ATG autophagy-related genes, BHPF fluorene-9-bisphenol, BPA bisphenol A, DBDPE decabromodiphenyl ethane, DEHP diethylhexyl phthalate, E₂ estradiol, F1 first generation, F2 second generation, FSH follicle stimulating hormone, GCs granulosa cells, LAMP2 lysosomal associated membrane protein 2, LC3 microtubule associated protein 1 light chain 3, LH luteinizing hormone, mTOR mechanistic target of rapamycin, P4 progesterone, PARKIN parkin RBR E3 ubiquitin-protein ligase, PBDE-47 2,2',4,4'-tetrabromodiphenyl, PINK1 PTEN-induced kinase 1, POI premature ovarian insufficiency, TICs theca-interstitial cells, TOCP triorthocresyl phosphate

Environmental pollutants-induced POI

Global industrialization and urbanization have led to escalating levels of environmental pollutants, posing significant threats to human health. Notably, diverse endocrine-disrupting chemicals (EDCs) such as BPA, 2,2',4,4'-tetrabromodiphenyl ether (PBDE-47), tri-ortho-cresyl phosphate, diethylhexyl phthalate, fluorene-9-bisphenol, decabromodiphenyl ethane, and nonylphenol are implicated in the pathogenesis of POI, with dysregulated ovarian autophagy identified as a key underlying mechanism [99, 209–214]. Autophagy typically acts as a trigger or mediator of ovarian injury induced by most EDCs. Contrastingly, perinatal exposure to bisphenol S uncovers a protective role for autophagy, mitigating oxidative stress and apoptosis [215]. The role of autophagy in PBDE-47 exposure appears dose-dependent: low doses induce protective autophagy, clearing damaged proteins and preventing injury, whereas high doses lead to concurrent overactivation of both autophagy and apoptosis, resulting in severe ovarian atrophy, cortical thinning, and oocyte depletion [216]. Thus, autophagy may function adaptively to support cell survival during initial insult but can exacerbate damage under sustained or severe toxicant exposure.

Beyond EDCs, POI could be developed from pesticides- (e.g., malathion, glyphosate), industrial pollutant- (e.g., melamine, acrylamide, ethylbenzene), heavy metal- (e.g., cadmium), and contaminated water/food-exposure, being manifested as reduced ovarian weight, disrupted estrous cycles and steroidogenesis, abnormal GC morphology/proliferation, impaired follicular/oocyte development, and reduced litter size [217–224]. In the above ovarian injury, autophagy is frequently overactivated, contributing to the onset and progression of POI [73, 225–228]. However, prenatal exposure to the mycotoxin fumonisin B1 presents an exception, wherein enhanced autophagy in second-generation ovaries represents a compensatory mechanism to restore ovarian homeostasis[229].

Unhealthy lifestyles-induced POI

Emerging evidence indicates that particular modifiable lifestyle factors significantly compromise female reproductive health, potentially correlating with POI. These factors include dietary imbalances, smoking, heat exposure, electromagnetic radiation, chronic unpredictable mild stress (CUMS), and adverse fetal/neonatal environments [184, 230–245].

Specific mechanistic pathways linking these factors to ovarian dysfunction often involve dysregulated autophagy. For instance, obesity elevates oxidized low-density lipoprotein levels, enhancing GC autophagy and promoting follicular atresia [230, 231]. Similarly, obese rats exhibit overactivated oocyte autophagy and retarded embryonic development [232]. Cigarette smoke exposure correlates with reduced ovarian indices, diminished primordial and growing follicles, and excessive autophagy [233–236]. Nutritional imbalance also impacts ovarian function: zinc deficiency impairs oocyte maturation, follicular development, and steroidogenesis via dirupting mitochondrial function and autophagy [237], while Wilson’s disease-associated copper dysmetabolism triggers follicular atresia and anovulation via endoplasmic reticulum stress-induced ferroptosis and intensified autophagy [184]. Environmental stressors like heat exposure impairs oocyte development by weakening autophagy [238, 239] but disrupts pregnant luteinizing cell structure and function via autophagy overactivation [240]. Furthermore, electromagnetic radiation exposure disrupts folliculogenesis concurrent with intensified ovarian autophagy and apoptosis in rats [241], and CUMS similarly promotes POI through excessive activation of autophagy and apoptotic pathways [242].

Early life insults exert long-term consequences; females exposed to maternal malnutrition during gestation/lactation exhibit diminished ovarian reserve or POI, associated with suppressed ovarian autophagy [243], while fetal hypoxia may detrimentally impact ovarian function through aberrant activation of autophagy and mitophagy [244, 245]. Collectively, these findings suggest that overactivated autophagy acts as a vital mediator underlying POI pathogenesis induced by most unhealthy lifestyle factors, contrasting with its protective role against zinc deficiency/heat exposure/malnutrition-induced ovarian injury. It is crucial to acknowledge the potential interplay of these lifestyle factors with other confounding variables modulating ovarian physiology. Future research should prioritize elucidating whether targeted therapeutic modulation of autophagy can effectively mitigate or reverse these lifestyle-associated ovarian damage.

Iatrogenic POI

Most clinically used chemotherapeutics lack tumor specificity, raising significant concerns about female reproductive toxicity [246]. Cisplatin, a broad-spectrum, cell cycle non-specific agent [247], elevates markers of endoplasmic reticulum stress, apoptosis, and autophagy in GCs and TICs [248]. Interventions demonstrate that suppressing autophagy may help alleviate its damage: for example, human umbilical cord mesenchymal stem cell (MSC) transplantation inhibits TIC autophagy and apoptosis, restoring ovarian function in cisplatin-treated rats [128], heat shock-preconditioned bone marrow MSCs reduce cisplatin-induced GC injury through autophagy inhibition [249]. Although upregulated autophagy typically promotes cisplatin-induced POI pathogenesis, transmural blood stem cell-conditioned medium enhances survival of exposed GCs with intensified autophagy, repeatedly suggesting its multifaceted regulatory effects [108].

Different cyclophosphamide regimens similarly induce ovarian toxicity but may elicit divergent autophagy responses [247, 250]. Primordial follicle depletion occurs along with either activation or inhibition of ovarian autophagy across different cyclophosphamide-exposed experimental models [134, 251]. Consequently, protective agents operate through opposing modulating of autophagy: AMH supplementation requires autophagy activation, whereas hyperoside necessitates autophagy inhibition [134, 251]. Triptolide, a traditional Chinese medicine with anti-inflammatory and anti-cancer properties, induces significant ovarian atrophy, and retarded oocyte development via overactivation of autophagy and apoptosis [101, 252].

Overall, ovarian autophagy serves as an important regulator of iatrogenic POI. While predominantly destructive, it may confer protection against chemotherapeutic damage in specific contexts. Elucidating the regulatory mechanisms of protective autophagy represents a critical research frontier, potentially enabling novel therapeutic strategies against chemotherapy-induced POI.

Autophagy modulation in DOR and POI treatment

Emerging preclinical evidence supports autophagy modulation as a promising therapeutic strategy for DOR and POI. Given that excessive autophagy activation has been noted in most POI models, therapeutic approaches frequently target its attenuation, including mitophagy inhibition [169, 191, 253–262]. Paradoxically, several agents demonstrate efficacy via contrasting mechanisms involving autophagy induction. For example, spermidine restores ovarian endocrine function and follicular reserve while activating autophagy in 3-nitropropionic acid-induced POI [263]. Similarly, trehalose, paeoniflorin, Zigui-Changqi decoction, and the humanin derivative [Gly¹⁴]-humanin exert protective effects through upregulation of GC autophagy [264–267].

Autophagy in PCOS pathogenesis

Polycystic ovary syndrome, the most prevalent endocrine-metabolic disorder in reproductive-aged women, is characterized by hyperandrogenism, chronic anovulation, and polycystic ovarian morphology, frequently associated with insulin resistance and obesity [268–270]. As a critical regulator of folliculogenesis, androgen biosynthesis, and CL function, ovarian autophagy is fundamentally implicated in PCOS pathogenesis [127]. This involvement is evidenced by dysregulated autophagy patterns across diverse PCOS models, with recent bioinformatic analyses further acknowledged autophagy/mitophagy-related genes as molecular correlates of the disorder.

Contrasting observations exist regarding autophagic activity in PCOS: while ovarian autophagy is mostly hyperactivated in both PCOS in vitro and in vivo models [271], a recent review reported cell-type-specific effects—functional autophagy in oocytes and GC supports follicular development and ameliorates PCOS, whereas autophagic inhibition in TICs alleviates PCOS via suppressing androgen overproduction [272]. Mechanistic studies reveal a PCOS-autophagy co-expression network featuring 29 ATGs, with BRCA1, LDLR, MAP1B, and NEAT1 proposed as diagnostic biomarkers [273]. However, subsequent clinical data challenge this paradigm, demonstrating that reduced serum ATG7 levels (indicative of downregulated autophagy) correlates with increased risks of PCOS [274]. The mechanisms regulating ovarian autophagy in PCOS pathogenesis include: (A) Under nutrient-deprivation circumstance, AMPK phosphorylation activates sirtuin 1 and deacetylates LC3. This leads to LC3 activation, its translocation from the nucleus to the cytoplasm, and initiates autophagosome formation upon binding to ATG7. (B) On the other hand, PCOS inflammation upregulates high mobility group box 1 protein, thereby activating autophagy. This results in GC autophagy and eventually cell death [9].

Core PCOS manifestations (hyperandrogenism, insulin resistance, anovulation) are pathogenically linked to autophagy dysregulation. Hyperandrogenism correlates with heightened GC autophagy and mitophagy in preclinical models [29, 275–278] and human GCs [279], potentially mediated by epigenetic modification of autophagy genes [280](Fig. 3). A recent bioinformatic analysis implicates mitophagy gene MAP1LC3A as a PCOS biomarker, being positively correlated with testosterone levels [281]. While overactivated autophagy is reported in GCs of PCOS models with insulin resistance [282, 283], clinical evidence paradoxically associates reduced serum ATG7 (indicating autophagy deficiency) with insulin resistance initiation [274]. Notably, hyperinsulinemia may further suppress autophagy via a negative feedback loop [284] (Fig. 3). The development of anovulatory phenotypes also involves intensified autophagy as suggested in DHEA-induced models [285, 286] (Fig. 3). Recently, the theory of a circadian-autophagy rhythm has been proposed as an additional mechanism in PCOS. A disrupted circadian rhythm in PCOS impairs normal body physology, promotes insulin resistance, hyperandrogenemia, and metabolic disorders. It also damages adaptive autophagic responses, contributing to PCOS pathogenesis, highlighting the role of circadian irregularities and autophagy impairment in PCOS [9].

Fig. 3.

Autophagy and PCOS. ATG: autophagy-related gene; TICs: theca-interstitial cells. In particular, upward arrows indicate elevation, downward arrows indicate reduction, circles with inner plus or minus maker are representative of promotion or inhibition

Multiple regulators—including bone morphogenetic protein 4, block of proliferation 1, cancer susceptibility candidate 15, cytoplasmic polyadenylation element binding protein 1, ferredoxin 1, homocysteine, Let-7e, sestrin 2, suppressor p53-sestrin1, taurine up-regulated 1, and Wnt family member 5A—modulate PCOS pathogenesis through manipulating ovarian autophagy [278, 286–294]. Emerging therapies taking effect through optimizing autophagy/mitophagy like umbilical cord-MSC-derived extracellular vesicles (suppressing GC mitophagy) and photobiomodulated cord blood plasma (inhibiting oocyte autophagy) appear as promising alternatives of PCOS drug [295, 296].

Autophagy-targeted therapies for PCOS

Therapeutic modulation of autophagy shows significant promise for PCOS management. ATG7 silencing or chloroquine administration (a lysosomal inhibitor) meliorates insulin resistance in PCOS patients [282], growing surveys into PCOS medications target ovarian or GC autophagy (Fig. 3). Multiple therapeutic agents demonstrate efficacy in ameliorating endocrine-metabolic disorders through autophagy modulation in preclinical models. These include: (1) botanical compounds (thymoquinone, clove extract); (2) traditional Chinese medicine formulations (GuiZhi FuLing Wan, BuShen JianPi, Bushen huoluo, CangFu Daotan decoctions); and (3) pharmacological agents (protocatechuic acid, clomiphene, dexamethasone, sitagliptin-rosiglitazone, and semaglutide) [275, 283, 297–307]. Paradoxically, ChaoNangQing prescription induces protective GC autophagy[308].

Clinical studies of autophagy modulators in POI and PCOS treatment

Emerging clinical evidence supports autophagy-modulating agents for non-neoplastic ovarian disorders (Table 2). Key compounds include activators (rapamycin, quercetin, metformin, resveratrol) [56, 82, 309, 310] and inhibitor hydroxychloroquine [311].

Table 2.

Modulators of autophagy in treatment of non-tumorous ovarian pathology

Disease	Human/animal model	Modulators of autophagy	In vivo/in vitro	Ovarian pathology	References
DOR/POI	Mice	Adipose-derived stem cell-derived exosomes	In vivo, in vitro	Improved ovarian morphology and function, increased serum estradiol (E2) levels, decreased FSH levels	[253]
		Curcumin	In vivo, in vitro	Increased ovary weight, number of primary and secondary follicles, the levels of serum E2, decreased number of atretic follicles	[254]
		Curculigoside	In vivo	Increased body weight, the number of normal follicles, AMH and E2, improved the development of abnormal follicles, reduced the number of atretic follicles and FSH level	[262]
		Spermidine	In vivo, in vitro	Restored estrogen secretion and regular estrous cycle, enhanced reproductive capacity, reduced follicular atresia, increased ovarian reserve	[263]
		[Gly14]-humanin	In vivo	Increased number of primordial follicles, primary follicles, secondary follicles, serum E2 and AMH level, litter size, decreased the number of atretic follicles	[265]
		Trehalose	In vivo, in vitro	Reduced D-gal-induced ovarian weight loss	[266]
		Paeoniflorin	In vivo	Improved ovarian development, increased ovarian weight, the number of follicles	[267]
	Rats	Human umbilical cord mesenchymal stem cell-derived small extracellular vesicles	In vivo	Improved ovarian morphology, promoted follicular development, inhibited follicular over-atresia, improved ovarian reserve capacity	[255]
		Dehydroepiandrosterone	In vivo	Improved ovarian function, increased ovarian volume, number of growing follicles and corpus luteum, decreased follicular atresia	[191]
		Bushen Huoxue formula	In vivo, in vitro	Increased E2, AMH, and LH levels, ovarian weight, decreased FSH levels, reduced follicular atresia, promoted follicular development	[257]
		Human Umbilical Cord Mesenchymal Stem Cells	In vivo, in vitro	Improved the body weight, ovarian organ coefficient, number of follicles at all levels, estrous cycle, and hormone levels	[258]
		XinJiaCongRongTuSiZiWan	In vivo, in vitro	Reduced follicular atresia, FSH and LH levels, increased the number of primordial and primary follicles, E2 and AMH levels	[259]
		Bone Marrow Mesenchymal Stem Cells and Moxibustion	In vivo	Increased ovarian weight and index, restored serum hormone levels, increased ovarian reserve, reduced follicular atresia	[260]
		Zigui Changqi Decoction	In vivo	Increased ovarian index, decreased FSH and LH levels, increased E2 and AMH levels	[264]
	Cow	Quercetin	In vivo, in vitro	Increased ovarian weight	[261]
PCOS	Human	Bu-Shen-Jian-Pi Formula	In vitro	Inhibited testosterone-induced autophagy	[306]
		Chao Nang Qing prescription	In vitro	Promoted apoptosis and autophagy, inhibited proliferation in granulosa cells	[308]
	Mice	Thymoquinone	In vivo, in vitro	Reduced the number of follicular cysts, restored normal follicular development, decreased LH/FSH ratio and total testosterone levels	[307]
		Guizhi Fuling Wan	In vivo, in vitro	Inhibited autophagy in granulosa cells	[304]
		Semaglutide	In vivo	Decreased testosterone levels, the number of ovarian cysts, increased estrogen levels, the number of corpora lutea, the thickness of the granulosa cell layer, normalized the disrupted estrous cycle	[297]
		Sitagliptin and Rosiglitazone	In vivo, in vitro	Increased the number of corpora lutea and improved their arrangement	[299]
	Rats	Acupuncture	In vivo	Reduced cystic follicles, LH, FSH, AMH and testosterone levels, increased granulosa cell layers, E2 levels	[300]
		Guizhi Fuling Wan	In vivo	Improved ovarian morphology, increased the number of mature follicles and corpora lutea, decreased the number of atretic and cystic follicles, promoted follicular development and ovulation	[301]
		Electroacupuncture	In vivo, in vitro	Reduced the number of cystic follicles, serum testosterone and LH levels, LH/FSH ratio, thickened granulosa cell layer, increased number of corpus luteum, FSH levels	[302]
		Bushenhuoluo Decoction	In vivo,in vitro	Decreased body weight and ovarian index, testosterone, LH, E2 levels, LH/FSH ratio, the number of primary follicles and cystic follicles, improved insulin sensitivity, increased number of corpus luteum, FSH levels	[275]
		CangFu Daotan Decoction	In vivo	Decreased ovarian cysts, serum LH and testosterone levels, increased granulosa cell layers, FSH levels	[303]
		CangFu Daotan Decoction	In vivo, in vitro	Reduced androgen levels, the number of polycystic ovaries, improved insulin resistance, ovarian blood flow, promoted follicular development and ovulation	[305]
		Clove Oil	In vivo	Improved the ovarian tissue, manifested as well-developed antral follicles, normal granulosa cell layer structure, and reduced number of follicular cysts	[283]
		Sitagliptin and Rosiglitazone	In vivo	Restored estrous cycle, decreased the number of atretic follicles and cystic follicles, serum levels of testosterone, LH, and LH/FSH, increased the number of corpus luteum, levels of E2, FSH	[298]
Clinical investigations	Human	Rapamycin	Cohort study	Reduced the duration of ovarian stimulation, the total dose of gonadotrophins required, increased the number of retrieved oocytes and mature oocytes, fertilization rates, implantation rates, and clinical pregnancy rates, live birth rate	[329]
		Resveratrol	Single-center, randomized, single-blind, controlled clinical trial	Increased the number of retrieved oocytes, MII oocytes, cleavage embryos, blastocysts, embryos available for cryopreservation, and fertilization rate	[330]
			Single-center, retrospective, cross-sectional study	Increased risk of miscarriage, reduced clinical pregnancy rate	[331]
		Hydroxychloroquine	Cohort study	Improved body fat distribution, glucose and lipid metabolism levels, hormonal disorders	[328]
		Quercetin	Randomized clinical trial	Improved oocyte and embryo grade and the pregnancy rate	[325]
			Randomized, double-blind, placebo-controlled trial	Decreased resistin plasma levels and gene expression, testosterone and LH levels	[326]
			Randomized placebo-controlled double-blind clinical trial	Improved the adiponectin-mediated insulin resistance and hormonal profile	[327]
		Melatonin	Prospective clinical trial	Improved Day 3 high-quality embryos rate, blastocyst rate of vitrified-warmed cleavage-stage embryos	[312]
			Cohort study	Improved fertilization rates, enhanced embryo quality	[313]
			Randomized controlled trial	Enhanced the quantity of oocytes retrieved, fertilization rates, and embryo quality, elevated biochemical pregnancy rates	[314]
			Randomized controlled trial	Enhanced oocyte and embryo quality	[315]
			Prospective, longitudinal, cohort study	Improved ovarian stimulation protocols and pregnancy outcomes	[316]
			Cohort study	Improved cytoplasmic maturation of human immature oocytes, clinical outcomes	[317]
			Randomized, double-blind, placebo-controlled trial	Improved mental health parameters, insulin levels, HOMA-IR, QUICKI, total and LDL cholesterol levels	[318]
			Randomized double-blind, placebo-controlled trial	Reduced serum TNF-α levels and hirsutism scores, improved oxidative stress markers	[319]
		Metformin	Randomized trial	Decreased serum levels of HOMA-IR, FAI, leptin, AMH and MDA; increased number of mature oocytes, fertilization rate and number of good-quality embryos	[320]
			Randomized, double-blind clinical trial	Increased progesterone levels, attenuated the menstrual cycle length,	[321]
			Randomized controlled pilot study	Decreased serum insulin and testosterone levels, increased the number of mature oocytes (MII stage)	[322]
			Prospective, randomized, open-label, parallel-group controlled trial	Improved fasting glucose, fasting insulin, and HOMA-IR, menstrual cycles, LH, FSH, progesterone, testosterone levels; reduced weight and BMI	[323]
			Cohort study	Improved insulin sensitivity and menstrual cycle, reduced body weight	[324]

AMH anti-Müllerian hormone, BMI Body Mass Index, DOR diminished ovarian reserve, E₂ estradiol, FAI free androgen index, FSH follicle stimulating hormone, HOMA-IR homeostatic model assessment of insulin resistance, LDL low-density lipoprotein, LH luteinizing hormone, POI premature ovarian insufficiency, QUICKI quantitative insulin sensitivity check index

Melatonin-alone or combined with magnesium/myo-inositol consistently improves oocyte/embryo quality and metabolic parameters [insulin, homeostasis model assessment of insulin resistance (HOMA-IR)] across randomized controlled trials (RCTs)[312–319]. Metformin monotherapy or with sitagliptin/liraglutide ameliorates insulin resistance, anovulation, HOMA-IR, free androgen index, and body mass index, and preserves oocyte quality based on data from RCTs[320–324]. Quercetin is proved to recover PCOS-related metabolic-endocrine disorder and improve oocyte/embryo quality[325–327]. Hydroxychloroquine is indicated to improve PCOS adiposity and glucose/lipid homeostasis[328]. Three-month treatment of rapamycin increases oocytes retrieval, fertilization, implantation, and pregnancy rates in a retrospective cohort with 168 endometriosis patients [329]. Resveratrol behaves in a timing-dependent manner: its pretreatment increases oocytes retrieval, fertilization rates, and embryo numbers of intracytoplasmic sperm injection cycle in a RCT [330], whereas its peri-transfer supplementation associates with reduced pregnancy rates and increased miscarriage risk in a retrospective study, indicating critical timing considerations for its therapeutic efficacy[331].

Conclusion and future perspectives

Autophagy critically sustains oocyte development, GC viability, hormone synthesis, primordial follicle pool formation, and follicular atresia. Emerging evidence implicates dysregulation of autophagy and mitophagy within oocytes or GCs, along with ovarian ferritinophagy, as significant contributors to ovarian aging. Notably, protective autophagy mitigates stress by clearing damaged cellular components, detrimental autophagy exacerbates ovarian damage—potentially via crosstalk with apoptosis or ferroptosis—manifesting as compromised oocyte competence, aberrant follicular development, and reduced ovarian reserve. Furthermore, uncontrolled autophagy amplification in GCs is linked to the pathogenesis and progression of both POI and PCOS. This catalytic role of autophagy in ovarian dysfunction has spurred interest in autophagy modulators as potential therapeutic strategies for POI and PCOS.

Nevertheless, key unresolved questions demand further investigation. Specifically, defining the boundary between protective and detrimental autophagy in ovarian pathophysiology is imperative. Elucidating the regulatory mechanisms governing detrimental autophagy in POI and PCOS development also remains a complex and ongoing challenge. Addressing these questions is crucial for advancing our understanding of the molecular underpinnings of POI and PCOS, ultimately facilitating the development of effective treatments.

Abbreviations

ADCD

Autophagy-dependent cell death

AMCD

Autophagy-mediated cell death

AMH

Anti-Müllerian hormone

AKT

Serine-threonine kinase B

AMPK

Adenosine monophosphate-activated protein kinase

ATG

Autophagy-related genes

Beclin1

Coiled-coil moesin-like BCL2-interacting protein 1

BPA

Bisphenol A

CKAP5

Cytoskeleton-associated protein 5

CL

Corpus luteum

Cry1

Cryptochrome 1

CUMS

Chronic unpredictable mild stress

DHEA

Dehydroisoandrosterone

DOR

Diminished ovarian reserve

E₂

Estradiol

EDCs

Endocrine-disrupting chemicals

FOXO3A

Forkhead box O3A

FSH

Follicle stimulating hormone

GCs

Granulosa cells

GV

Germinal vesicle

HOMA-IR

Homeostasis model assessment of insulin resistance

LAMP2

Lysosomal associated membrane protein 2

LC3

Microtubule associated protein 1 light chain 3

LH

Luteinizing hormone

MSC

Mesenchymal stem cell

mTOR

Mechanistic target of rapamycin

NCOA4

Nuclear receptor coactivator 4

P4

Progesterone

P62

Phosphotyrosine-independent ligand for the lck SH2 domain of 62 kd

PBDE-47

2,2’,4,4’-tetrabromodiphenyl

PCOS

Polycystic ovary syndrome

PI3K

Phosphoinositide 3-kinase

POI

Premature ovarian insufficiency

POR

Poor ovarian response

PPP4C

Protein phosphatase 4

PWRN1

Prader-Willi region non-protein coding RNA 1

RAB

Member RAS oncogene family

ROS

Reactive oxygen species

RCTs

Randomized controlled trials

TICs

Theca-interstitial cells

Authors’ contributions

Xianan Tang and Xiaofan Gao performed the literature search and drafted the original manuscript. Jinjin Zhang and Shixuan Wang devised the conceptual ideas. Tong Wu and Yueyue Gao contributed to discussion. Jinjin Zhang and Yueyue Gao contributed to revision. All authors approved the final manuscript.

Funding

This work was supported by the grants from the National Key Research and Development Program of China 2022YFC2704100 (SX.W), Natural Science Foundation of Hubei Province 2022CFB502 (D.H), the National Natural Science Foundation of China 82371648 (JJ.Z), and National Natural Science Foundation of China 82301849 (T.W).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.