Reproductive longevity is essential for fertility and influences healthy ageing in women1,2, but insights into its underlying biological mechanisms and treatments to preserve it are limited. Here we identify 290 genetic determinants of ovarian ageing, assessed using normal variation in age at natural menopause (ANM) in about 200,000 women of European ancestry. These common alleles were associated with clinical extremes of ANM; women in the top 1% of genetic susceptibility have an equivalent risk of premature ovarian insufficiency to those carrying monogenic FMR1 premutations3. The identified loci implicate a broad range of DNA damage response (DDR) processes and include loss-of-function variants in key DDR-associated genes. Integration with experimental models demonstrates that these DDR processes act across the life-course to shape the ovarian reserve and its rate of depletion. Furthermore, we demonstrate that experimental manipulation of DDR pathways highlighted by human genetics increases fertility and extends reproductive life in mice. Causal inference analyses using the identified genetic variants indicate that extending reproductive life in women improves bone health and reduces risk of type 2 diabetes, but increases the risk of hormone-sensitive cancers. These findings provide insight into the mechanisms that govern ovarian ageing, when they act, and how they might be targeted by therapeutic approaches to extend fertility and prevent disease.
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Full genome-wide association summary statistics for the discovery meta-analysis are available from the ReproGen website (www.reprogen.org). The MII oocyte dataset is available from the European Genome-Phenome Archive under accession EGAS00001004947 (https://ega-archive.org/studies/EGAS00001004947). Access to these data is granted in accordance with the ethics permissions under which the data were collected from participants and under appropriate GDPR compliant data processing agreements. Data from the following sites were used: SMR (https://cnsgenomics.com/software/smr/#eQTLsummarydata); Tabula Muris (https://tabula-muris.ds.czbiohub.org/); LDSC-SEG (https://github.com/bulik/ldsc/wiki/Cell-type-specific-analyses); RNA-seq samples (https://www.ebi.ac.uk/ena); human oocyte expression analyses: Gene Expression Omnibus GSE86146, GSE107746. Source data are provided with this paper.
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This research was conducted using the UK Biobank resource under application numbers 871 (Exeter) and 9797 (Cambridge). Full individual study acknowledgements can be found in the Supplementary Information. The authors wish to dedicate this work to the memory of Professor P. Solc.
Full individual study and author disclosures can be found in the Supplementary Information.
Peer review information Nature thanks Heng-Yu Fan and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.
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Extended data figures and tables
a, Key processes involved in follicular activity from fetal development to menopause showing the numbers of oocytes at each stage. b, Summary of key biological pathways involved in follicular activity and their relationship to stage of reproductive life. Follicles, consisting of oocytes and surrounding granulosa cells, are formed in utero and maintained as resting primordial follicles in the cortex, constituting the ovarian reserve. Follicles are sequentially recruited from the ovarian reserve at a rate of several hundred per month in childhood, peaking at around 900 per month at approximately 15 years of age. Following recruitment, follicles grow by mitotic division of granulosa cells and expansion of oocyte volume for almost six months until meiosis is reinitiated at ovulation and the mature oocyte is released into the oviduct. Waves of atresia (follicle death) accompany developmental transitions and growing follicles are continuously induced to undergo cell death such that, typically, only a single follicle matures to ovulate each month. As ovarian reserve declines, the rate of follicle recruitment decreases, but the preovulatory follicles continue to produce substantial amounts of oestrogen, while other important hormones such as anti-Müllerian hormone and inhibin-B decline, leading to upregulation of the hypothalamus–pituitary gonadal axis.
Analyses are separated into those intended to lead to understanding of biological mechanisms, and those that lead to insights into population genetics or epidemiology.
a–c, Comparison of effect estimates from: a, Cox proportional hazards regression in UK Biobank with linear regression effect estimates from the overall meta-analysis (‘Effect full meta-analysis’); b, Cox proportional hazards regression in UK Biobank with linear regression effect estimates from the meta-analysis excluding UK Biobank (‘Effect 1KG+BCAC’); c, linear regression in UK Biobank with linear regression effect estimates from the meta-analysis excluding UK Biobank (‘Effect 1KG+BCAC’). d–g, Comparison of linear regression effect estimates from: d, UK Biobank GWAS versus the meta-analysis of 1000 Genomes imputed studies; e, UK Biobank GWAS versus meta-analysis of samples from the Breast Cancer Association Consortium (BCAC); f, meta-analysis of BCAC samples versus the meta-analysis of 1000 Genomes imputed studies; g, 23andMe replication analysis (rescaled) versus overall meta-analysis. HR, hazard ratio from Cox proportional hazards model; r, Pearson correlation coefficient; blue line is y = x for reference. Note: P values <1 × 10−300 are shown as 1 × 10−300.
Extended Data Fig. 4 Deviation from additive effects and distribution of estimated heritability across chromosomes.
a–d, Genome-wide significant signals showing departure from an additive model. We tested the identified signals for departure from an additive allelic model. a, rs11668344 shows no deviation from an additive allelic model, b, c, rs11670032 (b) and rs28416520 (c) show deviation from the additive allelic model and a recessive effect. d, rs75770066 shows a heterozygote effect. The mean and 95% confidence interval around the mean estimate are shown for each genotype. The expected mean ANM for the heterozygotes is the average of the mean ANM in the homozygote groups. The dashed orange line shows the effect estimate by genotype from linear regression based on an additive allelic model. Estimated ANM for each genotype was calculated as constant from regression model + number alleles × effect estimate from regression model. The dashed grey line indicates the additive effect estimate by genotype from a model adjusting for the dominance deviation effect of the heterozygote group (solid grey line). All regression models were adjusted for centre, genotyping chip and genetic principal components. dom dev, dominance deviation. e, The percentage of the total heritability explained that was attributable to each chromosome (observed heritability) is compared with the expected proportion calculated on the basis of chromosome size. The heritability of ANM was not uniformly distributed across chromosomes in proportion to their size. The X chromosome did not explain more heritability than expected given its size, but chromosome 19 explained 2.36% (1.98–2.75) of the trait variance—greater than the individual contributions of nearly all larger chromosomes (weighted average for chromosomes 1–18: 1.7%, s.e 0.2%) and about 2.5 times more than expected given its size. This was partially attributable to a single locus at 19q13 which explained about 0.75% of trait variance and where we mapped six independent signals (Supplementary Table 2). The dashed line shows the mean ratio of expected to observed heritability across all chromosomes. Chromosome size was estimated based on the number of genetic variants.
a, Gene co-regulation network for genes relating to age at menopause. Nodes indicate genes that are either in a cis region from the GWAS or have been prioritized by Downstreamer; edges indicate a co-regulation relationship with a z-score > 4. Co-regulation is defined as the Pearson correlation between genes in a scaled eigenvector matrix derived from a multi-tissue gene network72. cis genes are defined as genes that are within 300 kb of a GWAS top hit for age at menopause. trans genes are defined as having been prioritized by Downstreamer’s co-regulation analysis and not being within 300 kb of a GWAS top hit. Downstreamer prioritizes genes by associating the gene P value profile of the GWAS (calculated using PASCAL71) to the co-regulation profile of each protein-coding gene. Only genes for which this association passes Bonferroni significance are shown as trans genes. Teal, cis genes; dark teal, trans genes; yellow, genes with a first-degree relation to MCM8. b, Gene co-regulation network showing the genes that have a first-degree relationship with MCM8 with a z-score > 4. Edge width indicates the z-score of the co-regulation relationship. Colours as in a, with the exception of yellow, as all genes have a first-degree relation to MCM8.
Extended Data Fig. 6 DNA damage response and repair pathways implicated in reproductive ageing in humans.
a, Consequences of replication stress annotated with genes involved that were within 300 kb of the ANM signals. b, Genes involved in downstream DNA damage response and repair pathways with those within 300 kb of an ANM signal shown in blue. A full list of genes involved in DNA damage response and apoptosis annotated with genome-wide signals for ANM is provided in Supplementary Table 19. MRN, MRN–MRE11–RAD50–NBS1 complex; RPA, replication protein A including a subunit encoded by RPA1; RFC, replication factor C including a subunit encoded by RFC1; 9-1-1, RAD9–HUS1–RAD1 complex.
Extended Data Fig. 7 Cluster plot of expression of consensus genes identified from the genome-wide analyses in germ cells across different developmental stages.
Genes were selected from the GWAS signals, based on in silico prioritization (Supplementary Table 5). Of the 283 consensus genes highlighted by the GWAS, 258 passed QC and were available in the expression dataset. Gene expression was measured in human fetal primordial germ cells84,85 and in oocytes and granulosa cells in adult follicles (dataset generated in this study). Plot shows z-scores, calculated by subtracting the mean TPM in all samples for a gene and dividing by the s.d. GC, granulosa cell; MII, meiosis II; PGC, primordial germ cell; Wks, weeks.
Open bar/dot groups: control maternal diet, normal ovarian reserve. Grey bar/dot groups: obesogenic maternal diet, reduced ovarian reserve. Dots, individual observations. Bar heights and error bars: mean ± s.e.m. a, Ovarian follicular reserve in young adulthood in wild-type mice. Total follicles per mm3 ovarian tissue at 12 weeks. n = 8 biologically independent animals from different litters in each group. P = 0.0091. b, Brsk1 expression in the same mice, measured using qRT–PCR and expressed as average copy number. P = 0.0001. c, Wee1 expression in the same mice, measured using qRT–PCR and expressed as average copy number. P = 0.0256. d, Dmc1 expression in the same mice, measured using qRT–PCR and expressed as average copy number. P = 0.00001. e, Mapt expression in the same mice, measured using qRT-PCR and expressed as average copy number. P = 0.0378. All panels, two-way ANOVA after correction for multiple hypothesis testing. *P < 0.05, **P < 0.01, ***P < 0.001.
a, Representative images of ovarian sections of 1.5- and 13.5-month-old wild-type (WT) and Chek2−/− mice stained with PAS-haematoxylin. Primordial follicles (inset (i)), primary follicles (inset (ii)), secondary follicle (white arrow) and antral follicle (black arrow) are shown. Scale bars, 200 μm. b–e, Number of follicles (by class and total) present in WT and Chek2−/− mouse ovaries. b, c, 1.5 months old; d, e, 13.5 months old. Numbers in parentheses show the total number of ovaries analysed. f, Serum AMH (ng ml−1) in 16–17-month-old Chek2−/− mice. Numbers in parentheses show the number of mice assessed. g–i, Gonadotrophin stimulation of 13.5-month-old females. Numbers in parentheses show: g, the number of MII oocytes retrieved per female; h, the number of MII oocytes fertilized; and i, the number of fertilized oocytes assessed for blastocyst formation. j, Litter size of WT and Chek2−/− females throughout the reproductive lifespan. Litter sizes from nine WT and five Chek2−/− females are shown. Breeding cages contained one male and one female. Generalized linear model analysis showed maternal age effect, but no effect of genotype on litter sizes. k, Image of healthy pups born to 13 month-old Chek2−/− females. b–i, Two-sample t-test and Fisher’s exact test were used to compare WT and Chek2−/− for statistical significance: *P < 0.05, **P < 0.025, ***P < 0.001. All P values are two-sided. Error bars indicate s.e.m. For boxplots: centre line, median; box limits, IQR; whiskers, 1.5 × IQR (b–g). an, antral follicle; pri, primary follicle; P0, primordial follicle; sec, secondary follicle. Mouse strain: maintained on a mixed background, C57BL/6 129Sv, accession number BRC03481 at the RIKEN Bioresource Centre.
Extended Data Fig. 10 Conditional knockout Chek1 females are infertile due to requirement for Chek1 during preimplantation embryo development.
a, Schematic of generation of conditional knockout mouse model of Chek1 (Chek1 cKO) in the female germline using Ddx4-Cre. A similar approach was used for Zp3-Cre. b, In ovarian sections stained with H&E, we found follicles, corpora lutea (CL) and oocytes which contain nuclear structures (arrowheads, magnified right panels). These findings suggest that oestrus cycles and ovulation followed by corpus luteum formation are independent of Chek1 disruption in oocytes in vivo. c, Litter size of Chek1 cKO females. Three females older than 5 weeks of age were mated with C57BL/6J males. Five independent littermate females (F/+, Tg−/Tg−; F/F, Tg−/Tg−; or F/+, Tg+/Tg−) were used as Chek1 controls (ctrl). While Chek1 control females delivered normally, Chek1 cKO females delivered no litters (Mann–Whitney test, **P = 0.0179). Thus, these results indicate that CHEK1 is essential in the female germline. d, Litter size of Chek1-cKO and control females using the Zp3-Cre during follicular growth. Three-month-old control (Chek1 F/F; Chek1 ctrl, n = 4) and conditional knockout (Chek1 F/F; Chek1 cKO with Zp3-Cre, n = 4) were consecutively mated three times with wild-type (Chek1+/+) males, and the number of live (left) and dead (right) pups was monitored. While Chek1 ctrl females delivered a normal number of live pups, Chek1 cKO females had only a reduced number of perinatally dead pups (Mann–Whitney U-test: ***P < 0.001, **P < 0.01). Numbers in parentheses show the number of litters. e, The mean number of all ovulated eggs (sum of MII oocytes and fertilized MII oocytes) per mouse with s.e.m. (Mann–Whitney U-test, P = 0.126). Each data point represents the number of eggs per mouse. Three- to five-month-old Chek1 ctrl (n = 3) and Chek1 cKO (n = 5) females were mated with wild-type (Chek1+/+) males after pMSG + hCG stimulation. The number of ovulated eggs isolated 18 h after hCG stimulation and additional 10 h cultured in vitro was scored. The number of mice is shown in parentheses. f, The proportion of fertilized MII oocytes to all ovulated eggs with a binomial confidence interval (Fisher’s exact test, *P = 0.012; 95% CI 1.9–6.0; OR, 2.62). Numbers in parentheses show the total number of analysed eggs. g, The proportion of embryos that developed to blastocysts with binomial confidence interval (Fisher’s exact test, ***P < 0.0001). Fertilized MII oocytes (zygotes) were isolated from females stimulated with pMSG + hCG 18 h after hCG administration and cultured in vitro for 96 h (approximately embryonic day (E)3.5) when development to blastocyst was scored. Data are pooled from four independent experiments. The number of embryos is shown in parentheses. h, Fertilized eggs from Chek1 ctrl (n = 18) and Chek1 cKO (n = 13) females were fixed and stained for DNA (DAPI). All fertilized eggs from both genotypes showed normal pronucleus formation. The data were pooled from two independent experiments. Asterisks, polar bodies. i, The majority of Chek1 ctrl embryos formed blastocysts (g), but Chek1 cKO embryos were arrested mainly at the 3–8-cell stages. Representative bright-field images are shown. j, Proportion of developmental stages 2 cell, 3–4 cell and 5–8 cell (Cochran–Armitage trend test, **P = 0.0073). Chek1 ctrl and Chek1 cKO zygotes were isolated from 13 Chek1 ctrl and 6 Chek1 cKO females stimulated with pMSG + hCG 18 h after hCG administration and cultured in vitro for 49 h. Embryos were fixed and stained for γH2AX by immunofluorescence. DNA was visualized by DAPI (l). k, Proportion of embryos with genome fragmentation with binomial confidence interval (Fisher’s exact test, ***P < 0.0001). Data are pooled from two independent experiments. The number of embryos is shown in parentheses. l, Chek1 ctrl and Chek1 cKO zygotes (j, k) were fixed and stained for γH2AX (magenta) by immunofluorescence. DNA (grey) was visualized by DAPI. Arrows, genome fragments; asterisks, polar bodies. These findings suggest that maternally expressed Chek1 is critical for genome integrity protection during first divisions of preimplantation embryos in mice. All P values are two sided. For boxplots: centre line, median; box limits, IQR; whiskers, 1.5 × IQR. Strains: C57BL/6-FVB mixed background for a–c (Chek1 cKO, Ddx4-Cre); C57BL6-CD1 mixed background (Chek1 cKO, Zp3-Cre) for d–l.
Extended Data Fig. 11 Extended reproductive lifespan in females carrying an extra copy of Chek1 (sChek1).
a, mRNA expression levels of Chek1 in oocytes; numbers in parentheses show the number of mice stimulated for retrieval of oocytes. b, Representative images of ovarian sections from 1.5- and 13.5-month-old wild-type (WT) and sChek1 mice stained with PAS-haematoxylin. Primordial follicles (inset (i)), primary follicles (inset (ii)), secondary follicle (white arrow) and antral follicle (black arrow) are shown. Scale bars, 200 μm. c–f, Numbers of follicles (by class and total) in WT and sChek1 littermates: c, d, 1.5 months old; e, f, 13.5 months old. Numbers in parentheses show the total number of ovaries analysed. g–j, MII oocytes retrieved in response to pMSG and hCG (g), proportion of euploid oocytes (h), proportion fertilized (i) and proportion developed to blastocysts (j) at different ages of WT and sChek1 mice. Numbers in parentheses show: g, the number of female mice stimulated for retrieval of oocytes; h, the number of oocytes assessed for aneuploidy; i, the number of MII oocytes fertilized; and j, the number of fertilized oocytes assessed for blastocyst development. k, Proportion of live births relative to transferred embryos from in vitro fertilized oocytes from aged mice (16 months); numbers in parentheses show the number of embryos transferred. l, Healthy pups born to 16-month-old sChek1 females after IVF. m, Litter sizes from F2 females or males from aged sChek1 females after IVF treatment in k, compared to females of equivalent ages that were naturally breeding. Note that for natural breeding there were two females and one male per breeding cage, whereas F2 cages contained a single male and one female. Therefore, litter sizes are an underestimate for the IVF-conceived pups. n, Litter sizes of WT and sChek1 females throughout their reproductive lifespan. Data are from six breeding cages, three for each genotype. Each breeding cage contained one WT male and two females that were either WT or sChek1. Generalized linear model analysis showed maternal age effect, but no effect of genotype on litter sizes. a–k, Two-sample t-test and Fisher’s exact test were used to compare WT and sChek1 for statistical significance: *P < 0.05, **P < 0.025, ***P < 0.001. All P-values are two sided. Error bars indicate s.e.m. For boxplots: centre line, median; box limits, IQR; whiskers, 1.5 × IQR (c–g, m). NB, natural breeding; F2-f, F2 female; F2-m, F2 male. Mouse strain: inbred from mixed background C57BL/6 129Sv.
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Ruth, K.S., Day, F.R., Hussain, J. et al. Genetic insights into biological mechanisms governing human ovarian ageing. Nature 596, 393–397 (2021). https://doi.org/10.1038/s41586-021-03779-7