Demonstration of the relationship between the hippo signaling pathway and ferroptosis in cumulus cells collected from women with diminished ovarian reserve

Ferroptosis is a distinct type of regulated cell death characterized by iron-dependent lipid peroxidation and oxidative stress. It has been implicated in ovarian disorders including endometriosis, polycystic ovary syndrome, and primary ovarian insufficiency. The Hippo signaling cascade has also been proposed to interact with ferroptosis mechanisms. However, this interaction remains unexplored in the context of diminished ovarian reserve (DOR). This study had explored effect of ferroptosis on follicular atresia in DOR development via the Hippo signaling pathway. 81 women receiving in vitro fertilization (IVF) treatment were assigned, including 46 diagnosed with DOR and 35 with normal ovarian reserve (NOR). Cumulus cells were collected and analyzed for the expression of ferroptosis-related genes (GPX4, EMP1) and Hippo signalling genes (MST1, LATS1, YAP1) via qRT-PCR. DOR patients exhibited a notable increase in expression of GPX4 and EMP1 (p=0.015 and p=0.024), suggesting ferroptosis activation and a compensatory antioxidant response. Follicular fluid reactive oxygen species (ROS) concentrations in were exhibited markedly higher levels in the DOR group (p=0.008), while iron concentrations remained similar. Mitochondrial activity in germinal vesicle (GV) oocytes, assessed via MitoTracker™, was reduced in DOR patients. Additionally, erastin-treated granulosa cells showed increased YAP expression, implying a possible link to Hippo signaling. Although no direct regulatory interaction was confirmed, findings suggest that ferroptosis contributes to DOR pathophysiology and may represent a therapeutic target. Keywords: Ferroptosis, diminished ovarian reserve, cumulus cells, oxidative stress, Hippo signalling pathway