. 2023 Jan 2;33(1):11–29. doi: 10.1038/s41422-022-00718-7

Table 1.

Pharmacological interventions for female reproductive longevity under research in mammalian models and clinical studies.

Pharmacological intervention	Strain and ages/timings of outcome measurements^a (all animals used were female)	Dosing regimen	Outcomes at the oocyte level^b	Outcomes at the ovarian follicle level^b	Outcomes related to the estrous cycles^b	Litter size and other mating outcomes^b	Other outcomes^b	Clinical evidence and other remarks
NAC¹⁵⁵ NAC is a prodrug of L-cysteine, which is a precursor of the biologic antioxidant glutathione. NAC is thus used as an antioxidant by replenishing the glutathione store. NAC is approved for treating paracetamol overdose and has been widely researched for multiple conditions related to oxidative stress.	– Kunming mice, – At 7–8 months and 12 months of age	Drinking water supplemented with 0.1 mM and 1 mM NAC from 4 weeks of age for 6–12 months	– Decrease in the number of poor-quality oocytes at 12 months of age – No change in the number of ovulated oocytes	NA	NA	– Increase in litter size at 7–8 months of age	– Increase in telomere length and telomerase activity in ovaries	NA
Vitamin C²³² Vitamin C, also known as L-ascorbic acid, is a water-soluble vitamin. Acting as an enzyme substrate and/or cofactor, it is required for the biosynthesis of collagen, L-carnitine, and certain neurotransmitters and involved in protein metabolism. It is also a physiological antioxidant by directly scavenging free radicals and indirectly restoring other antioxidants including α-tocopherol (vitamin E).	– NMRI mice – After 8, 12 and 33 weeks of treatment	Oral gavage of 150 mg/kg vitamin C daily in young adults (25–30 g, age not specified) for 33 weeks	– No change in the total volume of oocytes in antral follicles	– Increase in the number of granulosa cells – Increase in the total number of primordial, primary, and antral follicles at 12 and 33 weeks of treatment	NA	NA	– Increase in ovarian volume	NA
Vitamins C and E¹⁵⁷ The vitamin E group, comprising of tocochromanols (tocopherols and tocotrienols), is the major hydrophobic vitamin exclusively obtained from diet. It reacts with unstable lipid radicals produced in lipid peroxidation to protect cell membranes from oxidative damage.	– F1 hybrid mice (C57Bl/6JIco female × CBA/JIco male) – At the ages of 40–42, 50–52, and 57–62 weeks	Diet supplemented with 10 g/kg vitamin C and 0.6 g/kg vitamin E from first day of weaning or from 32 weeks of age	– Increase in oocyte number – Improvement in oocyte quality by a decrease in age-related chromosomal distribution abnormalities in oocytes	NA	– No effect except a decrease in the number of estrus cycles in the mice treated from weaning in comparison to the mice treated from 32 weeks of age	NA	NA	NA
Genistein^156,233 Genistein is a naturally occurring isoflavone derived from soy products. It exhibits multiple biological activities including anti-aging, antioxidant, phytoestrogenic and antineoplastic activities.	– Sprague-Dawley rats – At 15 months of age¹⁵⁶	Intragastric gavage of 160 mg/kg genistein daily from 11 months of age for 4 months	NA	– Increase in the number of healthy follicles – Decrease in the number of atretic follicles – Increase in the number, but no change in the percentage of primordial follicles – Decrease in the percentage of primary follicles	– Maintenance of estrous cycle	NA	NA	In a study²³⁴ feeding adult female cynomolgus monkeys at 9–15 years of age saturated fat and cholesterol-containing diets, the diet with soy protein source containing genistein has led to higher numbers of primary and secondary follicles compared to the other diet with casein- lactalbumin source.
	– Sprague-Dawley rats – At 4 months and 15 months of age²³³	Intragastric gavage of 160 mg/kg genistein daily from 3 months of age for 4 weeks and 11 months of age for 4 months	NA	– Increase in the number of healthy follicles – Decrease in the number of atretic follicles – Increase in the numbers of primordial and antral follicles at 15 months of age	– Maintenance of estrous cycle	NA	NA
Resveratrol^235,156,167 Resveratrol is a natural polyphenol derived from red grapes and found in several other plants. It has been widely investigated as a therapeutic treatment for multiple diseases due to its antioxidant, anti-aging, anti-inflammatory, and anti-neoplastic properties. Resveratrol has been shown to scavenge ROS, enhance antioxidant biosynthesis and induce sirtuin-1 signaling.	– Sprague-Dawley rats – At 15 months of age¹⁵⁶	Intragastric gavage of 25 mg/kg resveratrol daily from 11 months of age for 4 months	NA	– Increase in the number of healthy follicles – Decrease in the number of atretic follicles – Increase in the number, but no change in the percentage of primordial follicles – Decrease in the percentage of primary follicles	– Maintenance of estrous cycle	NA	NA	A cross-sectional retrospective study¹⁶⁷ showed a strong association between resveratrol oral supplementation (200 mg/day) in women during IVF-embryo transfer and a decrease in clinical pregnancy rate.
	– C57 mice – At 14–16 months of age²³⁵	Drinking water supplemented with 30 mg/L resveratrol from 6 weeks of age for 6–12 months	– Increase in oocyte number – Improvement in oocyte quality by better spindle morphology and chromosome alignment	– Increases in the numbers of primordial and primary follicles, as well as secondary and antral follicles – No change in atretic follicle number	NA	– Increase in litter size	– Prevention of telomere shortening and improvement in telomerase activity in ovaries
CoQ10²³⁷ CoQ10, also known as ubidecarenone, is a naturally occurring component in cell membranes. It is an essential electron carrier in mitochondrial respiratory chain. CoQ10 also functions as an antioxidant via inhibition of lipid peroxidation as well as protein and DNA oxidation.	– ICR mice – At 12 months of age	Subcutaneous injection of 22 mg/kg CoQ10, three times a week from 9 months of age for 12–13 weeks	– Improvement in oocyte quality by reduction in oocyte spindle defects – Improvement in oocyte mitochondrial function	– Increase in the numbers of primordial, primary, and secondary follicles	NA	– Increase in litter size	– Increase in ovulation rate	In the same study,²³⁶ resveratrol (10 mg/kg) or lipoic acid (33 mg/kg) using the same dosing regimen and mouse strain did not lead to an increase in the ovulation rate.
Apocynin^237,238 Apocynin, also known as acetovanillone, is a plant-derived polyphenol with multiple biological activities. It can suppress superoxide production by inhibiting NADPH oxidase.	– C57BL/6 J mice – At 15–19 and 35–49 weeks of age²³⁷	Drinking water supplemented with 5 mM apocynin from 8–12 weeks or 38–42 weeks of age for 7 weeks	NA	– No change in the number or percentage of follicles at different stages	NA	NA	– Improvement in redox homeostasis and reversal of age-related protein carbonylation increase in ovaries and uteri – Normalization of age-related inflammation factors and collagen expression in ovaries	NA
	– C57BL/6 J mice – At 8–12 weeks and 38–42 weeks of age²³⁸	Drinking water supplemented with 5 mM apocynin from 6 weeks of age until 8–12 weeks or 38–42 weeks of age	NA	NA	NA	– Increase in litter size – Increase in the number of uterine implantation sites	– Improvement in redox homeostasis and reversal of age-related protein carbonylation increase in uterus	NA
Acetyl carnitine and lipoic acid²³⁹ Both acetyl carnitine and lipoic acid are natural compounds in the body and have demonstrated anti-inflammatory and antioxidative properties. Acetyl carnitine is formed by the addition of an acetyl group to the amino acid carnitine while lipoic acid is derived from octanoic acid. Acetyl carnitine facilitates fatty acid metabolism while lipoic acid has been shown to increase glutathione synthesis and regenerate vitamins C and E.	– C57BL/6 mice – After 3, 6, 9 and 12 weeks of treatment	Drinking water supplemented with 100 mg/L acetyl carnitine and 40 mg/L lipoic acid from 3 weeks of age for 3, 6, 9 or 12 months of treatment	– Increase in oocyte number – Improvement in oocyte quality by reduction in oocyte chromosomal and spindle abnormalities – Improvement in oocyte mitochondrial function	NA	NA	NA	NA	NA
Dimethylfumarate (DMF)²⁴⁰ DMF is a lipophilic drug approved for treating psoriasis and sclerosis. It has been shown to activate the Nrf2 pathway and possess immunomodulatory and antioxidant properties.	– BALB/c mice – At 48 weeks of age	Oral administration of 50 mg/kg DMF daily from 32 weeks of age for 16 weeks	– Increase in oocyte number	– Increase in the number of primordial follicles – No change in the numbers of primary, secondary, and antral follicles	NA	NA	– Elevation of serum AMH – Increase in antioxidant levels and decrease in oxidative stress in ovaries – Increase in telomere mRNA and protein levels in ovaries	NA
Catalpol²⁴¹ Catalpol, a plant-derived iridoid glucoside, has been shown to have antioxidative, anti-inflammatory, anti-apoptosis, and neuroprotective properties.	– Sprague-Dawley rats – At 15 months of age	Oral gavage of 1, 3 or 5 mg/kg catalpol daily from 14 months of age for 4 weeks	NA	NA	NA	NA	– Alleviation in ovarian weight loss and structural abnormalities – Rejuvenation of ovarian granulocytes – Increase in serum estradiol and progesterone levels but decrease in serum follicle-stimulating and luteinizing hormone levels	NA
Metformin^177,179,242 Metformin is a first-line biguanide antidiabetic drug. It has been shown to reduce hepatic glucose production and intestinal glucose absorption and improve insulin sensitivity. Metformin is also used to treat polycystic ovarian syndrome and investigated as a longevity drug. Proposed mechanisms of its life-extending effects include activation of the AMPK pathway, as well as modulation of the gut microbiota and DNA methylation.	– C57BL/6 – At 54 weeks of age¹⁷⁷	Diet supplemented with 100 mg/kg metformin from 28 weeks of age for half a year	NA	– Increase in the numbers of primordial and primary follicles	– Maintenance of estrous cycle	NA	– Reduction in ovarian oxidative damage and senescence marker P16 – Maintenance of serum estradiol level	A prospective randomized trial²⁴² found that female IVF repeaters without PCOS and with a mean age of about 39 years who took 500 mg/day metformin for 8–12 weeks before and during ovarian stimulation have higher ongoing pregnancy and implantation rates compared to those untreated.
	– Wistar albino rats – At 12 weeks of age¹⁷⁹	Oral gavage of 100 and 200 mg/kg/day metformin from 8 weeks of age for four weeks	NA	– No significant change in the number of primordial, primary, or total follicles, except an increase in secondary follicle count with 200 mg/kg/day dose	NA	NA	– Decrease in endometrial thickness
2-DG¹⁸⁰ 2-DG is a glucose derivative that competitively inhibits glycolysis, thus mimicking glucose restriction. It is also an investigational anticancer and antiviral drug.	– C57BL/6 mice – At 7 weeks of age	Intraperitoneal injection of 100, 300 or 600 mg/kg 2-DG daily from 5 weeks of age for 2 weeks	NA	– Reduction in follicular activation by a decrease in the type 3a primary follicle count	NA	NA	NA	NA
NAD⁺ boosters^186,187 NAD⁺ is naturally synthesized in the body. It is a central coenzyme in energy metabolism and an essential redox cofactor. The NAD⁺ level decreases with age and NAD⁺ repletion via the use of NAD⁺ precursors has been investigated as a therapeutic approach in multiple age-associated conditions, such as cardiovascular and neurodegenerative diseases	– Mainly C57BL/6 mice – At 12–16 months of age¹⁸⁷	Drinking water supplemented with 0.5 or 2 g/L of nicotinamide mononucleotide from 12 or 13 months of age for 4 weeks	– Improvement in oocyte quality by better oocyte spindle assembly – Increase in oocyte yield, oocyte diameter and blastocyst formation rates (2 g/L)	NA	NA	– Increase in litter size – Increase in pregnancy rate and live birth rate (0.5 g/L)	NA	NA
	– C57BL/6 mice – At 12 months of age¹⁸⁶	Drinking water supplemented with 400 mg/kg/day of nicotinamide riboside from 8 months of age for 4 months	– Improvement in oocyte quality by better oocyte spindle assembly – Improvement in mitochondrial functions in ovaries and oocytes	– Increase in the numbers of primordial, primary, and total follicles	– Maintenance of estrous cycle	– Increase in litter size	– Increase in ovary size and the number of ovulated cumulus–oocyte complexes after superovulation	NA
α-ketoglutarate (AKG)²⁴³ AKG is a key intermediate in the Krebs cycle, a nitrogen scavenger and a precursor of glutamate and glutamine. AKG can enhance protein synthesis, bone development and immune responses. It has also demonstrated life-extending effect by inhibiting ATP synthase and TOR.	– ICR mouse – At 8 and 14 months of age	Drinking water supplemented with 2, 10, 25, and 50 mM (optimal: 10 mM) AKG from 2 to 14 months of age	– Increase in oocyte number – Improvement in oocyte quality by reduction in abnormalities in mitochondrial distribution and spindle arrangement	– Increase in the number of primordial and primary follicles – No significant change in the numbers of secondary, mature and atretic follicles	– No significant effect in estrous cycle	– Increase in litter size, pregnancy rate and pregnancy outcomes – Decrease in neonatal death rate	– Reduction in telomere shortening	NA
Melatonin^218–229 Melatonin is an amine neurohormone primarily secreted by pineal gland at night. Besides its role of maintaining circadian rhythm, melatonin also acts as a potent antioxidant and a direct free radical scavenger, speculatively through the Nrf2-ARE pathway and sirtuin activation. Moreover, melatonin has been shown to increase lifespan in some animal models.	– Holtzman rats – At 75, 180 and 380 days of age²¹⁸	Drinking water supplemented with 10 μg/mL melatonin from 10 days of age, either only at night or continuously for one year	NA	– No change in the number of primordial follicles	– Decrease in estrous cycles with abnormal length with treatment only at night	NA	NA	Several clinical trials^224–229 have investigated the effects of oral administration of melatonin, usually at the dose of 3 mg daily, in women with infertility or a history of IVF failures. Positive changes of gonadotropins, decrease in degenerate oocytes, improvement in oxidative balance and oocyte quality and/or a slight increase in IVF fertilization rate have been found in some studies,^{224–226,229} However, other studies,^226–228 including one using a high dose of 8 mg twice daily, have failed to demonstrate an increase in clinical pregnancy rate, live birth rate or quality or quality of oocytes during IVF.
	– Wistar rats – At a) 5, b) 15 and c) 24 months of age²¹⁹	Subcutaneous injection of 150 μg/100 g daily from a) 3, b) 13 and c) 22 months of age for two months	– b) Increase in oocyte volume – a) b) c) No change in oocyte density	NA	– b) Improvement in estrous cycle regularity	NA	– b) Increase in ovarian volume – a) c) No change in ovarian volume – a) b) Maintenance of serum estradiol level
	– Kunming mice – At 14–16 months of age²²¹	Drinking water supplemented with 10 mg/kg melatonin from 2–3 months of age for 6–12 months	– Increase in oocyte number – Improvement in oocyte quality by better spindle morphology and chromosome alignment	– Increase in primordial follicle count – Decrease in atretic follicle count – No change in growing or mature follicle counts	NA	– Slight increase in litter size	– Improvement in ovarian mitochondrial antioxidant activity – Increase in telomere length – Suppression of ovarian apoptosis
	– ICR mice – At 43 and 53 weeks of age²²⁰	Drinking water supplemented with 100 μg/mL melatonin from 10 to 43 weeks of age	– Increase in the number of ovulated oocytes	– Increase in numbers of primordial, primary, and antral follicles	NA	NA	– Increase in telomere length – Increase in rates of fertilization and blastocyst formation following IVF
	– Kunming mice – At 24–48 weeks of age²²²	Drinking water supplemented with 10−3, 10−5, 10−7 mol/L (optimal: 10−5 mol/L) melatonin from 8 to 24–48 weeks of age	– Increase in oocyte number – Improvement in oocyte quality by improved morphology and blastocyst formation – Reduction of ROS formation in oocytes	NA	NA	– Increase in litter size	– Improvement in ovarian antioxidant capacity – Increase in the number of formed blastocysts and litter size following IVF
	– Kunming mice – On a) postnatal day 6 and 9 and b) postnatal day 15, 17, 19 and 21²²³	Injection of 1 and 15 mg/kg melatonin daily a) from postnatal day 3 to 9 and b) from postnatal day 10 to 21	– b) No change in oocyte diameter – b) Decrease in oocyte number after superovulation	– a) Decrease in the number of activated follicles, but no change in atretic follicle number – b) Decrease in the numbers of type 5b follicles and atretic follicles	– b) No change in estrous cycle	– b) Decrease in the number of implanted embryos with bigger embryo size	– a) Improvement in ovarian antioxidant capacity – b) Decrease in Fshr and Lhcgr gene expressions
Rapamycin^{4,6,207,208,210,244} Rapamycin, also known as sirolimus, is a natural anti-fungal macrolide produced by the bacterium Streptomyces hygroscropicus. Currently approved as an immunosuppressant, it has demonstrated therapeutic potential in other aspects, such as antiproliferation and immunomodulation in cancer treatment. Rapamycin has also been shown to extend both lifespan and healthspan in multiple animal models by inhibiting the target of rapamycin (TOR), a highly conserved key protein kinase regulating metabolism and physiology.	– C57BL/6 mice – At 8 weeks of age²⁴⁴	Intraperitoneal injection of 2 doses of 5 and 50 mg/kg rapamycin from 8 weeks of age for two consecutive days	– Reduction in ovulated eggs with unaffected quality	– No change in follicle reserve	NA	NA	NA	NA
	– Sprague-Dawley rats – At 20 weeks of age²⁰⁷	Intraperitoneal injection of 5 mg/kg rapamycin every other day from 10 weeks of age for 10 weeks	NA	– Suppression of primordial follicle activation by an increase in primordial follicle number – Decrease in numbers of antral and atretic follicles and corpora lutea	– Disturbance of estrous cycle, during or just after treatment	NA	– Reduction in ovarian weight
	– Adult rats – Age not specified²¹⁰	Intraperitoneal injection of 5 mg/kg rapamycin every other day for 10 weeks	NA	– Suppression of primordial follicle activation by an increase in primordial follicle number – Decrease in numbers of antral and atretic follicles and corpora lutea	– Disturbance of estrous cycle, during or just after treatment	– Failure of being impregnated	NA
	– C57BL/6 mice – At a) postnatal day 7 or b) postnatal day 21²⁰⁸	Intraperitoneal injection of 1 mg/kg rapamycin a) on postnatal day 2 and b) from postnatal day 7 and then every other day until postnatal day 21	NA	– Suppression of primordial follicle activation by an increase in primordial and transitory follicle numbers and decrease in the numbers of primary and activated follicles	NA	NA	NA
	– CD1 mice – Just after treatment, 2 months after treatment, and 16 months of age⁴	Intraperitoneal injection of 2 mg/kg rapamycin daily from 8 weeks or 8 months of age for 2 weeks	– No change in oocyte number – Improvement in oocyte quality by morphology and spindle arrangement	– Suppression of primordial follicle activation by an increase in primordial follicle number and decrease in the numbers of primary, secondary, and antral follicles	– Disturbance of estrous cycle, during or just after treatment – Re-normalization and maintenance of estrous cycle and hormone biogenesis 2 months post treatment	– Improvement in late-life fecundity	NA
	– C57BL/6 mice – At 130 days of age⁶	Intraperitoneal injection of 4 mg/kg rapamycin every other day from 37 days of age for 93 days	NA	– Suppression of primordial follicle activation by an increase in primordial follicle number and decrease in the numbers of primary, secondary, and tertiary follicles	NA	NA	NA

^aIn vivo studies on aged wild-type animals and clinical studies treating infertile women without a particular confounding disease (e.g., PCOS, POI).

^bOutcomes in comparison with untreated age-matched control in each study unless otherwise stated.