Invest Clin 64(4): 513 - 523, 2023 https://doi.org/10.54817/IC.v64n4a8

Corresponding Author. Halis Suleyman. Department of Pharmacology, Faculty of Medicine, Erzincan Binali Yildi-

rim University, Erzincan, Turkey, Post code: 24100, Phone: +90 4462261818, Fax: +90 5309211909, E-mail: halis.

suleyman@gmail.com

Stress-associated ovarian damage, infertility,

and delay in achieving pregnancy

and treatment options.

Gulsah Aynaoglu Yildiz1, Omer Erkan Yapca2, Kemal Dinc3, Cebrail Gursul4,

Betul Gundogdu5, Mehmet Aktas6, Zeynep Suleyman7, Seval Bulut7 and Halis Suleyman8

1Department of Perinatology, Etlik Zubeyde Hanim Maternity and Women’s Health

Teaching and Research Hospital, Ankara-Turkey.

2Department of Obstetrics and Gynaecology, Faculty of Medicine, Ataturk University,

Erzurum-Turkey.

3Department of Obstetrics and Gynaecology, Faculty of Medicine, Erzincan Binali

Yildirim University, Erzincan-Turkey.

4Department of Physiology, Faculty of Medicine, Erzincan Binali Yildirim University,

Erzincan-Turkey.

5Department of Pathology, Faculty of Medicine, Ataturk University, Erzurum-Turkey.

6Department of Biochemistry, Faculty of Medicine, Erzincan Binali Yildirim University,

Erzincan, Turkey.

7Department of Pharmacology, Health Sciences Institute, Erzincan Binali Yildirim

University, Erzincan, Turkey.

8Department of Pharmacology, Faculty of Medicine, Erzincan Binali Yildirim University,

Erzincan, Turkey.

Keywords: ovarian damage; sertraline; cerebrolysin; stress; rats.

Abstract. Many types of stress, including psychological stress, nega-

tively affect reproductive health. This study aimed to investigate the ef-

fects of sertraline (a selective serotonin reuptake inhibitor), cerebrolysin

(neuroprotective/neurotrophic), and a combination of both against stress-

induced ovarian damage, infertility and pregnancy delay in female rats.

The rats were divided into five groups (n=14/each group) as healthy (HG),

stress control (StC), stress+sertraline (SS), stress+cerebrolysin (SC), and

stress+sertraline+cerebrolysin (SSC). To induce stress, animals (except

the HG) were kept in a supine position with their forelimbs and hindlimbs

(FIM) tied for one hour. Then, sertraline (20mg/kg) was given orally to

the SS. Cerebrolysin (2.5ml/kg) was injected into the SC subcutaneously.

Sertraline+cerebrolysin was administered to SSC with the same methods and

doses. FIM and drug administration continued for 30 days. Six rats from each

514 Aynaoglu Yildiz et al.

Investigación Clínica 64(4): 2023

Daño ovárico, infertilidad y retraso en la concepción

relacionados con el estrés y opciones de tratamiento.

Invest Clin 2023; 64 (4): 513 – 523

Palabras clave: daño ovárico; sertralina; cerebrolisina; estrés; ratas.

Resumen. Muchos tipos de estrés, incluido el estrés psicológico, afectan

negativamente a la salud reproductiva. El objetivo de este estudio fue investigar

los efectos de la sertralina (un inhibidor selectivo de la recaptación de sero-

tonina), la cerebrolisina (neuroprotector/neurotrófico) y una combinación de

ambos contra el daño ovárico, la infertilidad y el retraso del embarazo inducido

por el estrés en ratas hembra. Las ratas se dividieron en cinco grupos (n=14/

cada grupo), como sanas (HG), control de estrés (StC), estrés+sertralina (SS),

estrés+cerebrolisina (SC) y estrés+sertralina+cerebrolisina (SSC) . Para indu-

cir el estrés, los animales (excepto el HG) se mantuvieron en posición supina

con las extremidades anteriores y posteriores (FIM) atadas durante una hora.

Luego, se administró sertralina (20 mg/kg) por vía oral al grupo SS. Cerebro-

lysin (2,5 mL/kg) se inyectó al grupo SC por vía subcutánea. Se administró

sertralina+cerebrolisina al grupo SSC con los mismos métodos y dosis. La FIM

y la administración de fármacos continuaron durante 30 días. Se sacrificaron

seis ratas de cada grupo con anestesia de dosis alta, se extirparon los tejidos

de los ovarios derecho e izquierdo y se examinaron bioquímica e histopatológi-

camente. Las ratas restantes se tomaron para reproducción. La exposición al

estrés en ratas provocó un aumento de los niveles de malondialdehído (MDA),

factor de necrosis tumoral alfa (TNF-α), interleucina-1β (IL-1β) e interleuci-

na-6 (IL-6) y una disminución del glutatión total (tGSH). El estrés se relacionó

con daño histopatológico, infertilidad y retraso en el parto. La combinación de

sertralina y cerebrolisina fue la más efectiva para prevenir estos cambios, con

sertralina y cerebrolisina solas en segundo y tercer lugar, respectivamente. Los

inhibidores selectivos de la recaptación de serotonina (ISRS) y los medicamen-

tos relacionados pueden ser beneficiosos en el tratamiento del daño ovárico

relacionado con el estrés, la infertilidad y el retraso en el embarazo.

Received: 13-05-2023 Accepted: 08-08-2023

group were euthanized with high-dose anesthesia, right and left ovarian tissues

were removed, and tissues were examined biochemically and histopathologi-

cally. The remaining rats were taken for breeding. Exposure to stress in rats

caused an increase in malondialdehyde (MDA), tumor necrosis factor-alpha

(TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6) levels and a decrease

in total glutathione (tGSH). Stress was related to histopathological damage,

infertility, and delayed birth. The sertraline and cerebrolysin combination was

the most effective in preventing these changes, with sertraline and cerebroly-

sin alone in second and third places, respectively. Regarding efficacy, selective

serotonin reuptake inhibitors (SSRIs) and related drugs may be beneficial in

treating stress-related ovarian damage, infertility, and delay in pregnancy.

Stress-related ovarian damage and infertility 515

Vol. 64(4): 513 - 523, 2023

INTRODUCTION

One of the fundamental reasons for psy-

chological stress is socioeconomic factors1.

It has been known that chronic stress is

related to numerous diseases 2. Abnormali-

ties that cause infertility, such as ovulation,

implantation disorders, and tube damage,

have also been connected with psychological

stress 3. Many types of stress, including psy-

chological stress, harm fertility and repro-

ductive functions 4. There is information in

the literature that stress triggers depression

and anxiety 5.

Furthermore, it is stated that depres-

sion and anxiety lead to infertility 6. It has

been observed that oxidative stress and pro-

inflammatory cytokine production increase

in depression and anxiety 7. Degeneration,

infiltration, and histopathological damage ,

such as atretic follicles, are seen in response

to stress in rat ovaries 8. Kadioglu et al. re-

vealed that stress, which leads to infertility,

increases total oxidant levels and decreases

antioxidant levels in rat ovarian tissue 9. This

literature recommends that drugs with anti-

oxidant, antidepressant, anti-inflammatory,

and anxiolytic effects may be beneficial in

treating stress-related ovarian damage and

reproductive dysfunction.

Sertraline, is an antidepressant drug

with selective serotonin re-uptake inhibitor

antioxidant properties 10. It has been experi-

mentally revealed that sertraline exerts an

anti-inflammatory effect by reducing tumor

necrosis factor-alpha (TNF-α) levels 11. It has

been suggested that the antidepressant and

anxiolytic effect of sertraline is based on the

suppression of excessive production of TNF-α,

interleukin-6 (IL-6), interleukin-1beta (IL-

1β), and other pro-inflammatory cytokines

12,13. Cerebrolysin is another drug we would

like to see for its effects on stress-related

ovarian damage, infertility, and preventing

delay in maternity. Cerebrolysin is a porcine

brain-derived drug with neuroprotective and

neurotrophic effects and contains low mo-

lecular weight peptides and amino acids 9. It

has been defended that the antidepressant

effect of cerebrolysin is based on its reduc-

ing oxidative stress and cytokine-related in-

flammation 14. In addition, it has been argued

that using an antidepressant drug with a drug

with neuroprotective properties increases the

effectiveness of antidepressant treatment 15.

All this information shows that sertraline,

cerebrolysin, and a combination of both may

be beneficial against increased stress, ovar-

ian damage, infertility, and delay in achieving

pregnancy in animals. This study aimed to

investigate the effects of sertraline, cerebro-

lysin, and the combination of both on stress-

induced ovarian injury, infertility, and preg-

nancy delay in rats.

MATERIALS AND METHODS

Animals

Seventy albino Wistar female rats pro-

vided by the Medical Experimental Applica-

tion and Research Center of Ataturk Uni-

versity weighing between 272-288 grams at

6 months of age were utilized in our study.

Rats were placed in a laboratory with a 12-

hour light/12-hour dark cycle at appropri-

ate humidity (45%) and temperature (22°C)

and fed ad libitum before experimentation.

Experimental applications were carried out

considering the ARRIVE guidelines. The im-

plementation of the experiment was started

after the procedures were approved by the

Atatürk University Animal Experiments Lo-

cal Ethics Committee (date: 27.12.2018,

meeting no: 13/253).

Chemicals

Sertraline was procured from PFIZER

(Turkey), cerebrolysin from EVER Pharma

(Austria), and sodium thiopental from IE Ul-

agay (Turkey).

Animal groups

The rats were randomly separated into

healthy controls (HG), stress-applied con-

trol (StC), stress+sertraline (SS), stress +

cerebrolysin (SC), and stress+ sertraline +

516 Aynaoglu Yildiz et al.

Investigación Clínica 64(4): 2023

cerebrolysin (SSC) groups, with 14 animals in

each group.

Experiment procedure

Stress was induced in rats by the

forced immobilization method (FIM). For

the implementation of this experiment, all

animals except the HG group were placed

in the supine position; their hindlimb and

forelimbs were tied and kept in this posi-

tion for one hour. After one hour, sertraline

(20 mg/kg) was given to the SS rat group

by oral gavage. SC group was injected with

cerebrolysin (2.5 mL/kg) subcutaneously.

Sertraline+cerebrolysin was administered to

the SSC group at the indicated doses under

the same method. The HG and StC groups

were given the same volume of distilled wa-

ter. FIM and drug applications were contin-

ued once a day for 30 days. Six rats from

each group were euthanized (ip, 50 mg/kg

thiopental sodium), and the right and left

ovarian tissue were removed for biochemi-

cal and histopathological examination. The

rest of the animals were kept in the same

environment with mature male rats for two

months for pregnancy.

The rats that were found to be pregnant

were taken into separate cages and fed. Rats

that did not become pregnant and give birth

during this period were considered infertile.

In addition, the time from the day the fe-

male rats were placed in the same cage with

the male rats to the day they gave birth was

determined. The delay in maternity was de-

termined by subtracting the standard gesta-

tional period (21 days) from this period.

Biochemical analyses

Preparation of samples

Ovarian tissues were weighed. Tissues

were made up to 2 mL with 1.15% potassium

chloride solution for MDA determination

and phosphate buffer with pH=7.5 for GSH

determination and homogenized in an ice-

cold medium, it was centrifuged for 15 min-

utes (10000 rpm, +4 °C). The supernatant

portion was utilized as an analysis sample.

Malondialdehyde (MDA) and Total

Glutathione (tGSH) Analysis

Malondialdehyde was measured to estab-

lish the oxidation level, tGSH was measured to

determine the antioxidant level. MDA measure-

ments were made according to the method de-

fined by Ohkawa et al. 16. tGSH measurement

was performed in line with the method defined

by Sedlak and Lindsay 17.

Tumor Necrosis Factor-ɑ (TNF-α),

Interleukin 1-β (IL-1β), and Interleukin-6

(IL-6) Analysis

Tumor Necrosis Factor-ɑ, IL-1β, and

IL-6 were measured to assess the pro-inflam-

matory status. The samples were weighed,

and then all tissue was cut. These samples

were then snap-frozen with liquid nitrogen

and homogenized using a mortar and pestle.

After the samples were melted, they were

kept at 2-8 °C. PBS (pH 7.4), 1/10 (w/v) was

added; after this, vortexed for 10 seconds,

centrifuged at 10000 xg for 20 minutes, and

supernatants were aliquoted. TNF-α, IL-1β,

and IL-6 levels were measured using a com-

mercial kit (Eastbiopharm Co Ltd ELISA kit,

China).

Histopathological Examination

After the tissue samples were defined

in 10% formaldehyde solution, they were

washed in the cassettes under tap water

for 24 hours. They were then treated with

conventional-grade alcohol to remove wa-

ter from the tissues, passed through xylol,

and embedded in paraffin. Sections of 4-5

microns were taken from these paraffin

blocks and subjected to hematoxylin-eosin

staining. Tissues were examined under a

light microscope, and then photographs

were taken (Olympus® Inc. Tokyo, Japan,

DP2-SAL firmware program). Ovarian tis-

sues were evaluated regarding congestion,

hemorrhage, degeneration in follicle cells,

water accumulation in follicle cells, cystic

changes in follicles, and edema. The sever-

ity of histopathological findings was graded

from 0-3 (0-normal, 1-mild injury, 2-moder-

Stress-related ovarian damage and infertility 517

Vol. 64(4): 513 - 523, 2023

ate injury, and 3-severe injury). Histopatho-

logical evaluation was performed by a pa-

thologist who was blinded to treatment and

group allocations.

Statistical Analysis

This study used the “IBM SPSS 22® (Ar-

monk, NY: IBM Corp.)” program for statisti-

cal analysis. Since the biochemical data were

numeric, the analysis was done with one-way

ANOVA, Tukey was used as a post hoc test,

and the results were presented as Mean ±

Standard error (X±SEM). Since the histo-

pathological data were sequential, Kruskal-

Wallis was preferred for analysis, and then the

Dunn’s test was used. Data were presented as

Median (Minimum-Maximum), p<0.05 was

accepted as statistical significance.

RESULTS

Biochemical Results

MDA and tGSH Analysis

The levels of MDA in the StC group

(5.87±0.02) were significantly higher than

in the HG (1.34±0.06), SS (2.85±0.02), SC

(3.45±0.08) and SSC (1.52±0.06) groups as

can be seen in Fig. 1A (p˂0.001). The increase

in MDA levels in the SSC group was observed

to be significantly lower than in the SS and SC

groups (p˂0.001). For MDA, the HG and SSC

groups were similar (p=0.123). The amount

of tGSH measured in the ovarian tissue of the

StC (1.30±0.05) group was observed to be

significantly lower than the values measured

in the HG (6.00±0.19), SS (3.64±0.08), SC

(2.37±0.05) and SSC (5.42±0.18) groups

(p˂0.001). In the treatment combination

group, inhibition in the decrease of tGSH was

more significant than in the sertraline and

cerebrolysin groups (Fig. 1B).

TNF-α, IL-1β and IL-6 Analysis

As seen in Fig. 2, TNF-α (Fig. 2A), IL-1β

(Fig. 2B) and IL-6 (Fig. 2C) levels in the StC

group (6.73±0.05, 8.05±0.17, 8.52±0.23,

respectively) were significantly increased

compared to HG (1.73±0.17, 2.25±0.04,

2.87±0.12, respectively), SS (3.27±0.04,

4.28±0.11, 4.89±0.03, respectively), SC

(4.66±0.05, 5.81±0.04, 6.82±0.03, respec-

tively) and SSC (2.04±0.10, 2.39±0.05,

3.14±0.03, respectively) groups (p˂0.001).

The increase in TNF-α, IL-1β, and IL-6 levels

was significantly lower in the combination

group when compared with the SS and SC

groups alone (p˂0.001). Cytokine levels were

similar in SSC and HG groups (p>0.05).

Fig. 1. MDA (A) and tGSH (B) levels in the ovarian tissue of study groups.

*p=0.123 vs SSC group; **p˂0.001 vs SS and SC groups; ***p˂0.001 vs HG, SS, SC and SSC groups.

Statistical analysis was done with one-way ANOVA, followed by the Tukey test. HG, healthy group;

StC, stress-treated control group; SS, stress+sertraline group; SC, stress+cerebrolysin group; SSC,

stress+sertraline+cerebrolysin group.

518 Aynaoglu Yildiz et al.

Investigación Clínica 64(4): 2023

Reproduction Test Results

Animals in the HG group gave birth

within 23-26 days, as observed in Table 1. Six

of the eight rats in the SS group gave birth

within 27-36 days, while two did not give

birth within two months. Three of the eight

rats in the SC group gave birth within 33-38

days, but three did not give birth within two

months. In the SSC group, all eight female

rats gave birth on days 24-28. One of eight

female rats in the StC group gave birth on

day 49, but the remaining seven did not give

birth during this time.

Histopathological findings

As seen in Fig. 3A and Table 2, no path-

ological findings were found in the ovarian

tissue of the HG group; corpus luteum and

follicle structure were observed within nor-

mal limits. Grade-3 degenerated secondary

follicle and congestion were observed in the

ovarian tissue of the StC group (Fig. 3E, Ta-

ble 2). Moreover, grade-3 dilated congested

vessels, hemorrhage, and edema were seen

in the ovarian tissue of the StC group (Fig.

3F, Table 2). Vascular congestion (grade-1)

and relatively normal follicle and corpus lu-

teum structure (grade-0) were seen in the

ovarian tissue of the SS group treated with

sertraline (Fig. 3B, Table 2). In the SC group,

mild fluid accumulation in the lumen, cystic

changes (grade-1), minimal vascular conges-

tion (grade-1), and corpus luteum damage

(grade-1) were detected (Fig. 3C, Table 2).

There were no histopathological signs other

than mild vascular congestion (grade-1) and

relatively normal corpus luteum (grade-0) in

the SSC group (Fig. 3D, Table 2).

DISCUSSION

The effects of sertraline, cerebrolysin,

and their combination against FIM-related

stress-associated ovarian damage, infertility,

and delay in achieving pregnancy in female

rats were investigated in this study. Various

stress factors lead to damage to all organs

and tissues of the body, as can be understood

from the literature 18. Previous studies have

revealed that psychological or physiological

stress is related to oxidative stress 19. Stress

increased the levels of MDA, known as the

toxic product of lipid peroxidation (LPO),

and decreased the antioxidant tGSH levels

in the ovarian tissue of animals, as can be

observed in our results. These biochemical

findings show that stress changes the oxi-

dant-antioxidant balance in favor of oxidants

in the ovarian tissue. In the literature, it has

been shown that stress increases oxidants in

ovarian tissue while decreasing antioxidants

20. As it is known, membrane lipids are oxi-

dized by reactive oxygen species (ROS), and

a toxic product, MDA, is formed. MDA re-

sulting from LPO greatly disrupts the struc-

ture and functions of the cell membrane

Fig. 2. TNF-α (A), IL-1β (B), and IL-6 (C) levels in the ovarian tissue of study groups.

*p>0.05 vs SSC group; **p˂0.001 vs. SS and SC groups; ***p˂0.001 vs. HG, SS, SC and SSC groups.

Statistical analysis was done with one-way ANOVA, followed by the Tukey test. HG, healthy group;

StC, stress-treated control group; SS, stress+sertraline group; SC, stress+cerebrolysin group; SSC,

stress+sertraline+cerebrolysin group.

Stress-related ovarian damage and infertility 519

Vol. 64(4): 513 - 523, 2023

Fig. 3 (A-F). Histopathological examination of ovarian tissues in study groups. A. Ovarian tissue of the SG

group; view of healthy corpus luteum (star) and follicle structure (arrow) within normal limits. B.

Ovarian tissue of the StC group; Section showing degenerated secondary follicle (bilateral arrow),

dilated congested blood vessel (straight arrow). C. Ovarian tissue of the StC group; section showing

dilated congested blood vessel (straight arrow), hemorrhage, and edema (bilateral arrow). D. Ova-

rian gland of the SS group; Section showing congested blood vessels (arrows), the follicle (star),

and corpus luteum (zigzag arrow). E. Ovarian tissue of the SC group; Follicle structure with fluid

accumulation in the lumen and cystic change (arrow), section showing mild congestion (zigzag

arrow). F. Ovarian tissue of the SSC group; Section, showing mildly congested blood vessel (zigzag

arrow), corpus luteum (star). H&E x 200. HG, healthy group; SS, stress+sertraline group; SC,

stress+cerebrolysin group; SSC, stress+sertraline+cerebrolysin group; StC, stress-treated control

group. H&E x 200.

Table 1

Infertility and reproductive process in rats preproductiveprocess in rats.

Groups Non-infertile rats

n %

İnfertile rats

n %

Reproductive process

(RP) (day)

Delay in maternity

(RP-21 days)

HG (n=8) 8 100 - - 24.63 ± 0.42* 3.63 ± 0.42*

SS (n=8) 6 75 2 25 30.17 ± 1.45** 9.17 ± 1.45**

SC (n=8) 3 37.7 5 62 36.00 ± 1.53*** 15.00 ± 1.53***

SSC(n=8) 8 100 - - 25.75 ± 0.59 4.75 ± 0.59*

StC (n=8) 1 12 7 88 49.00 28.00

*, p>0.05 vs SSC; **, p<0.05 vs SC and SSC, ***; p<0.05 vs SS and SSC. Statistical analysis was done with

one-way ANOVA, followed by the Tukey test. Results are expressed as mean±standard error of the mean.

HG, healthy group; StC, stress-treated control group; SS, stress+sertraline group; SC, stress+cerebrolysin group;

SSC, stress+sertraline+cerebrolysin group; n, number of animals.

520 Aynaoglu Yildiz et al.

Investigación Clínica 64(4): 2023

and leads to further destruction 21. As such,

MDA level is known as a marker of oxidative

stress and antioxidant status in patients 22.

Our results, which align with these previous

findings, showed that the amount of tGSH

decreased significantly. At the same time,

MDA increased in the ovarian tissues of ani-

mals exposed to stress. GSH is a tripeptide

that can be found in most cells. GSH pro-

tects cells from the toxic effect of ROS by

detoxifying hydrogen peroxide and organic

oxides 23.

It is known that pro-inflammatory cyto-

kine production plays a role in parallel with

excessive oxidant production in the patho-

genesis of ovarian damage, infertility, and

delay in achieving pregnancy that develops

due to stress and other factors 9,24. Our re-

sults, accordingly, showed that TNF-α, L-1β

and IL-6 levels increased in the ovarian tis-

sue of animals with infertility and delay in

achieving pregnancy. In studies with pa-

tients, it has been reported that TNF-α, IL-

6, and other pro-inflammatory cytokines are

among the factors that lead to infertility in

ovarian pathologies 25. Oxidative stress and

pro-inflammatory cytokines increase in psy-

chological disorders such as depression and

anxiety, as mentioned above 7.

It has been reported that stress is asso-

ciated with depression, and depression may

lead to ovarian dysfunction 26. Sertraline

was more effective than cerebrolysis against

stress-related ovarian damage, infertility,

and pregnancy delay. The fact that sertraline

is more effective than cerebrolysin may be

due to its more significant inhibition of over-

production of oxidant and pro-inflammatory

cytokines than cerebrolysin. Sertraline has

antioxidant properties as mentioned here-

inabove 10. Moreover, it is argued that the

antidepressant and anxiolytic effect of ser-

traline is based on suppressing excessive

production of TNF-α, L-1β, IL-6, and other

pro-inflammatory cytokines 12,13. It has been

documented that the antidepressant effect

of cerebrolysin is due to the reduction of oxi-

dative stress and cytokine-related inflamma-

tion 14. Cerebrolysin is also a neuroprotec-

tive and neurotrophic drug 27. The fact that

the use of an antidepressant drug together

with a drug with neuroprotective properties

increases the effectiveness of the treatment

has been reported in the literature 15. The

administration of sertraline and cerebroly-

sin in combination suppressed oxidant and

inflammatory markers in ovarian tissue bet-

ter than sertraline and cerebrolysin adminis-

tered alone. It also better prevented stress-

related infertility and delay in achieving

pregnancy in our study.

Severe histopathological injury was

seen in the ovarian tissue of the stress

group. In addition, mild cystic changes in

Table 2

Histopathological examination of ovarian tissues.

Groups Congestion Hemorrhage Follicle cell

degeneration

Water

accumulation in

follicle cells

Cystic change

in follicles

Edema

HG (n=6) 0(0-0)* 0(0-0)* 0(0-0)* 0(0-0)* 0(0-0)* 0(0-0)*

SS (n=6) 1(0-2)* 0(0-0)* 0(0-1)* 0(0-0)* 0(0-0)* 0(0-0)*

SC (n=6) 1(0-2)* 0(0-0)* 0(0-0)* 1(0-2)** 1(1-1)** 0(0-0)*

SSC (n=6) 1(0-1)* 0(0-0)* 0(0-0)* 0(0-0)* 0(0-0)* 0(0-0)*

StC (n=6) 3(2-3)** 3(3-3)** 3(2-3)**- 0(0-0)* 0(0-0)* 3(2-3)**

Histopatological grading; 0-normal, 1- mild injury, 2-moderate injury, and 3-severe injury. *, p>0.05 vs other groups

with the same sign; **, p<0.05 vs other groups. Kruskal Wallis test was used. Results are expressed as median

(minimum -maximum). HG, healthy group; SS, stress+sertraline group; SC, stress+cerebrolysin group; SSC,

stress+sertraline+cerebrolysin group; StC, stress-treated control group.

Stress-related ovarian damage and infertility 521

Vol. 64(4): 513 - 523, 2023

the follicles and water accumulation in the

follicle cells were observed in the stress and

cerebrolysin group, while adding sertraline

to the treatment prevented these changes.

Combination therapy, sertraline, and cere-

brolysin were the best suppressors of his-

topathological damage, respectively. It is

known that oxidant and pro-inflammatory

cytokines lead to hemorrhage, congestion,

follicle degeneration, inflammatory cell in-

filtration, and necrosis in the ovarian tissue

24. Infertility and delay in achieving preg-

nancy developed in the stress-treated con-

trol group in which severe histopathological

damage was detected in the ovarian tissue,

as can be understood from our results. Ince

et al. reported severe follicle degeneration

in ovaries with high MDA and low tGSH lev-

els 28. In another study by Ince et al. stated

that severe degeneration was found in the

ovarian follicles of animals in which sterility

and delay in achieving pregnancy developed

29. It was revealed in the study of Kadioglu

et al. that the stress induced by the forced

immobilization method causes widespread

congestion, hemorrhage, accumulation of

fluid, and inflammatory infiltration in the

subcapsular area in the ovaries. Infertility,

delay in achieving pregnancy, decrease in

the number of offspring, and intrauterine

physical developmental retardation were

found in the animal group with these histo-

pathological signs 9. The stress induced by

the FIM has led to oxidative and inflammato-

ry damage in the ovarian tissue of animals,

sterility, and delay in achieving pregnancy.

The combination therapy of sertraline and

cerebrolysin were the drugs that best pre-

vented ovarian damage, infertility, and delay

in achieving pregnancy, respectively. This

information has revealed the fact that anti-

depressant drugs with antioxidant and anti-

inflammatory effects might be useful in the

treatment of stress-related ovarian damage,

infertility and delay in achieving pregnancy.

It has been revealed particularly that the

combination of antidepressant (sertraline)

and neuroprotective / neurotrophic (cere-

brolysin) drug combination may be more

beneficial. In line with this information

sertraline, cerebrolysin and their combi-

nation may be preferred in treating stress-

associated ovarian damage, infertility, and

delay in achieving pregnancy. However, it is

required to investigate antidepressant and

neuroprotective/neurotrophic drug combi-

nations from different groups in the future

to confirm these findings.

ACKNOWLEDGMENTS

We want to thank Erzincan Binali Yildir-

im University Experimental Animals Applica-

tion and Research Center for their contribu-

tions.

Conflict of interest

There is no conflict of interest among

the authors.

ORCID number of authors

• Gulsah Aynaoglu Yildiz (GAY):

0000-0002-3283-7783

• Omer Erkan Yapca (OEY):

0000-0002-5578-0126

• Kemal Dinc (KD):

0000-0003-4955-455X

• Cebrail Gursul CG):

0000-0001-6521-6169

• Betul Gundogdu (BG):

0000-0002-3786-3286

• Mehmet Aktas (MA):

0000-0003-1931-8353

• Zeynep Suleyman (ZS):

0000-0003-0128-7990

• Seval Bulut (SB):

0000-0003-4992-1241

• Halis Suleyman (HS):

0000-0002-9239-4099

522 Aynaoglu Yildiz et al.

Investigación Clínica 64(4): 2023

Participation of authors

Substantial contribution to conception

and design: GAY, HS; Acquisition of data:

MA, HS; Analysis and interpretation of data:

KD, ZS, SB; Drafting of the manuscript: GAY,

OEY, HS; Critical revision of the manuscript

for important intellectual content: GAY, HS;

Statistical analysis: ZS, SB; Research group

leadership: GAY, HS; Have given final approv-

al of the submitted manuscript: GAY, OEY,

KD, CG, BG, MA, ZS, SB, HS.

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