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

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 E 2 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 mice 5 (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 E 2 , 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 E 2 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 E 2 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 E 2 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, E 2 , 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 E 2 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 E 2 , 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 E 2 , 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 E 2 , 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 E 2 TICs AMPK, p-AMPK/AMPK, LC3 II ↑ mTOR, p-mTOR/mTOR↓ [ 128 ] Triptolide In vivo, in vitro Decreased primary follicles and secondary follicles, E 2 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 E 2 , 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 E 2 , 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, E 2  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 Autophagy in multifactor-induced POI Environmental pollutants-induced POI Unhealthy lifestyle-induced POI AMPKα−1, LC3-II:LC3-I↑ AKT, mTOR↓ LC3, ATG7↑ P62↓ LC3, Beclin1,LC3-II:LC3-I↑ ATG12-ATG5↓ Iatrogenic POI LC3-II:LC3-I↑ P62↓ 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, E 2  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 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 ]. 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. 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. 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 [Gly 14 ]-humanin exert protective effects through upregulation of GC autophagy [ 264 – 267 ]. 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 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 ]. 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 ]. 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 (E 2 ) levels, decreased FSH levels [ 253 ] Curcumin In vivo, in vitro Increased ovary weight, number of primary and secondary follicles, the levels of serum E 2 , decreased number of atretic follicles [ 254 ] Curculigoside In vivo Increased body weight, the number of normal follicles, AMH and E 2 , 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 E 2 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 E 2 , 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, E 2 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 E 2 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, E 2 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, E 2 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 E 2 , 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, E 2  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 Modulators of autophagy in treatment of non-tumorous ovarian pathology AMH anti-Müllerian hormone, BMI  Body Mass Index, DOR  diminished ovarian reserve, E 2  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 ].

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.

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.