ENDO-optimize 2.0: New formula for better and stronger beneficial effects on your oocyte quality, PCOS and endometriosis-related symptoms
Posted By Braverman IVF & Reproductive Immunology || 29-August-2018
Endo-Optimize new formula is now available for purchase online.
At the cutting edge of innovation, we, at Braverman Reproductive Immunology, have a constant interest in discovering new therapy or ingredient able to significantly improve your reproductive health. To this end, we have updated our Endo-Optimize formula, with new ingredients such as, Acai Berry, L-Arginine and DIM, and it is now combined with our Green Formula and Myo-inositol.
Thus melatonin should be added to your regimen and is now provided separately and available for purchase online.
Taken once a day, our new formula does not contain melatonin (as melatonin should be taken at night only).
3 New ingredients to further improve your fertility and reduce PCOS and endometriosis related symptoms
1- Açaí Berry
a- What is Açai Berry?
Euterpe oleracea Mart. (Arecaceae), commonly known as “Açaí”, is a palm fruit from the Amazon region of Brazil (1) with antioxidative, antinociceptive, anti-inflammatory, and anticancer activities.
a- A triple action against inflammation, oxidative stress and diabetes for a great benefit in patient with PCOS and poor oocyte quality
Açai contains high amounts of flavonoids and is rich in carbohydrates, that compose around 42% of the fruit total weight in a dry basis (2). The polysaccharides extracted from açaí, especially type II arabinogalactan are responsible, at least in part, for its modulation on the immune function (3-4) with: Immunostimulatory effects
Açai’s flavonoids also exert anti-inflammatory (5) and anti-oxidative actions.
Açai’s flavonoids antioxidant activity involves the direct scavenging and quenching of oxygen free radicals such as ROS and the inhibition of oxidative enzymes (superoxide dismutase) that generate these reactive oxygen species (6).
Isovitexin, one of açaí’s flavonoids has the strongest anti-oxidative potential while velutin, another one of acai’s flavonoids has the strongest anti-inflammatory effect (7) by inhibiting NF-KB activation, a master regulator of inflammation (8).
Acai was also found to be a potential cyclooxygenase (COX)-1 and COX-2 inhibitor, reducing prostaglandin production thus minimizing inflammation (9). Besides its anti-inflammatory and antioxidant capacity, açaí can improve lipid profile as seen in young healthy athletes (10) and has anti-diabetic effects in animal models with high cholesterol (11-12) by:
lowering cholesterol levels.
significant reduction of hepatic inflammation
improvement of glucose metabolism
c- Açaí Berry and Endometriosis
In a rat model for breast cancer (13), açaí treatment decreased the number of inflammatory cells and activated macrophage, it also inhibits angiogenesis as seen by a reduction of VEGF and its receptor VEGFR-2. The açaí-treated rat had lower activity of the enzyme COX-2 leading to a significant reduction of PGE2 levels (inflammatory mediator).
Açaí has also shown great potential as an antiproliferative agent and as an inducer of apoptosis in leukemia cells (14)
Antiangiogenic, anti-proliferative, pro-apoptotic and anti-inflammatory potential of açaí may also have beneficial effects on endometriosis.
Indeed, a study (15) investigated the therapeutic potential of acai on the growth and survival of endometriotic lesions using an experimental model.
Acai treatment (ingestion) in a rat model for endometriosis significantly:
Decreased the endometriosis implant size (showing atrophy and regression of endometriotic lesions)
the acai-treated group showed lower concentrations of PGE2, VEGF and NO (marker of oxidative stress) compared to the control group.
lower number of activated macrophages
In addition, macrophages cells (playing a key role in the lesions development and growth) treated with acai, in vitro, underwent apoptosis (-50% in cell survival). Therefore, lower macrophages number reduces ROS production which in turn lowers inflammatory and angiogenesis processes in endometriotic lesions.
This study clearly suggest that acai can effectively suppressed the establishment and growth of endometriotic lesions.
a- What is L-Arginine?
L-arginine is an amino acid present in body fluids (16) that plays a role in the maintenance of immune homeostasis (17-18). It is a precursor for the synthesis of proteins.
b- How does it work?
L arginine is a well-known anti-oxidant thanks to its free radical scavenging capacity (20-21). It is involved in the regulation of T-cell and macrophage functions (22-23) and L-arginine supplementation may be of clinical benefit in improving wound healing and immune responses (24-25)
c- Anti-inflammatory, antioxidant and antidiabetic properties
In a study (26), male rat on a high fat diet supplemented with L ariginine showed after 6 weeks:
reduction of TNFα serum levels
increase in the total antioxidant status
decrease in insulin resistance
The antioxidant effects of L-arginine could be due to the decreasing intensity of radical reactions (through its binding properties to free radical). L-arginine may reduce superoxide anion release from endothelial cells, and thus lowering oxidative stress (27-28) By reducing the number of free radicals, L-arginine inhibits tissue damage and decreases inflammation status in rats which has been previously shown in several pathologies (29-30).
d- L-arginine is a key amino acid supplying energy during critical stage of oocyte and embryo development
During folliculogenesis (production of a fertilizable oocyte or “egg), there is a high demand of energy to support oocyte growth and development.
Many studies have shown that L-arginine transport (31) and depletion (32) is one of the most important during oocyte development.
This high turnover further increased in aging patient (33) shows L-arginine’s role in supporting the highly demanding oocyte growth and maturation. During embryo development, there is an increasing requirement for energy and metabolites to support cell division, and L-arginine has been shown to be one of the key amino acid supporting this process (34).
e- L-arginine, NO and PCOS
Nitric oxide (NO) is synthesized by nitric oxide synthase (NOS) during the conversion of L-Arginine to citrulline using oxygen and NADPH as the cofactors. NO plays various function in human reproductive functions (35)
While an excess in NO production has been linked to inflammatory disease, hypertension or diabetes, maintaining adequate amount of NO is a prerequisite for its proper functioning of the biological system.
In PCOS patients (36), low NO production and low L-arginine bioavaibility have been reported.
Further, lower levels of regulatory T cells (Treg) have been shown in PCOS patient.
Knowing the key role of NO in female reproduction and Treg generation, L-arginine deficiency could be one of the cause in infertility associated with PCOS.L arginine supplementation could restore adequate NO levels and have a positive impact on fertility in PCOS patient as suggested (37).
a- What is DIM?
DIM or Diindolylmethane is a natural phytonutrient found in cruciferous vegetables such as broccoli, brussels sprouts and cabbage. It is produced after the catalyze of a specific nutrient, namely, acid- idole-3-carbinol (I3C) in the stomach.
b- How does it work?
Estrogen hormones can be metabolized into two different oxidized forms: 2OHE2 and 4OHE2.
While 2OHE2 binding to the receptor alpha of estrogen (Erα) leads to no transcriptional activity, 4OHE2 can be further hydroxylated into a carcinogenic metabolite (semiquinone/quinine)
DIM promotes the selection of certain enzymatic pathways and methylation of estrogen in the liver, leading to estrogen being broken down into a less harmful form.
c- DIM’s antiproliferative and antiangiogenic properties can help minimize endometriotic lesions growth
DIM treatment induces a cell proliferation arrest in the cell cycle of breast, ovarian, prostate, and colon cancer cell lines (38) and is even able to induce apoptosis in human tumoral cells (39).
DIM has been shown to suppress the proliferation of endometrium cancer cell line too (40). DIM is a negative regulator of estrogen by inhibiting ERα signaling (41-42) and therefore could be of prime interest in counteracting estrogen deleterious effect in endometriosis.
DIM has been shown to inhibit the migration and invasiveness of cells which can minimize endometriotic lesions establishment.
DIM has been shown to decrease angiogenesis as seen by reduced levels of VEGF which can minimize endometriotic lesions establishment.
Altogether, these actions can help limit endometriotic lesion growth and development.
In addition, DIM balances your hormones which can help regain a normal follicle development and ovulation.
Endo-Optimize New Formula contains all the previous ingredients that made it the best product on the market and is now combined with our Green Formula
1- Myo-inositol: optimizer of the ovarian function
Myo-inositol belongs to the vitamin B complex. It is the precursor for the synthesis of phosphoinosides, which are part of the phosphatidylinositol signal transduction pathway (43). This pathway is responsible of signal transduction across the plasma membrane, via a second messenger, inositol 1,4,5-triphosphate, that modulates intracellular Ca2+ release as seen in Figure 2.
Figure 2: Phosphatidyl inositol pathway leading to calcium release
Myo-inositol and the ovarian function
Through its effects on the calcium pathway, myo-inositol plays a direct and key role on the maturation of an oocyte (egg) which leads to better oocyte quality and increased ovulation rate (44-46). Further this has an impact on fertilization and early embryo development (47).
Thus, myo-inositol significantly increases fertilization and pregnancy success rate (48) which is suggested by its role during the stages of early development in the embryo (49).
Indeed, a double blinded trial (44) assessed the effects of myo-inositol on the ovarian function by comparing PCOS patients on 2g MYO + 200mcg folic acid (twice a day) for 3 months (treated group) versus PCOS patients on 200mcg folic acid (twice a day) for the same period length (control group).
The oocyte quality was assessed at ovum pick up and showed:
rFSH administrated during stimulation was significantly lower in the treated group which significantly decreases the risk of hyperstimulation.
Increased number of oocytes retrieved in the treated group (12 versus 8.5)
Higher % of mature oocyte in the treated group (82% versus 63%)
% of immature oocyte (degenerated or vesicle germinal) was significantly reduced in the treated group (2.3% versus 24%)
Higher % of score 1 embryos (good quality embryo) in the treated group (70% vs. 30%).
The treatment with myo-inositol in addition to melatonin improves ovarian stimulation protocols and pregnancy outcomes in infertile women with poor oocyte quality (48).
It is important to also highlight that levels of myo-inositol in the follicular fluid are good marker of oocyte quality in animal study (50) but also in women during IVF procedure (51). Further, myo-inositol is also able to significantly lower leptin levels that are markers for poor oocyte quality (52).
Myoinositol and PCOS
Another important aspect of inositols is their role as insulin-sensitizers that could have several benefits in PCOS patients. Besides their powerful antioxidant potential (53) that reduces oxidative stress, myo-inositol can also help decrease hyperandrogenism (lowering testosterone levels) and sensitize the ovary to insulin (54).
Further, a study assessing hormonal parameters in obese PCOS patients before and after 12 weeks of treatment (55) with myo-inositol at 2g/day in addition to folic acid (200mg) and comparing the changes to control individuals (treated with folic acid 200mg only) showed exclusively in patients treated with myo-inositol: A significant reduction in insulin levels
A significant reduction in prolactin levels
A significant reduction in LH levels
In addition, myo-inositol had a clear impact on treated patients’ fertility who had much higher % of top-quality oocytes (82% vs. 36%) resulting in 40% of clinical pregnancies (vs 16% for the control group).
Myo-inositol supplementation is efficient in positively modulating many of the hormonal disturbances of PCOS, and overall leading to better ovarian function.
It could be used as an agent to help restore better oocyte quality leading to better embryo quality and higher chances of getting pregnant.
A natural fertility enhancer
The maturation of an oocyte leading to ovulation is a complex process requiring the formation of the meiotic spindle and the production of energy by mitochondria (56). A disrupted mitochondrial function could lead to arrest of oocyte maturation, chromosomal misalignment, and could compromise embryo development (57-59). CoQ10 is an essential component of the electron transport chain involved in energy (ATP) production (60), further it has critical anti-oxidant properties (61).
A murine model for ovarian aging showed that mitochondria are not fully functional in aged ovaries as seen by decreased metabolic activities (62). As a result, aged animals produced oocytes with spindle defects leading to misaligned chromosomes (that will induce impaired cell division). Interestingly, most of these abnormalities could be partially or completely corrected by the administration of CoQ10 in animal models. Besides changes in the mitochondria, it has been shown that older animals have lower number of granulosa cells (GC, cells surrounding the oocyte and supporting the growth of the oocyte) and these cells express lower CoQ10 expression levels. CoQ10 treatment significantly increases GC numbers in these aged mice (63). In the same study, the genetic deletion in the oocyte of a specific enzyme Pdss2 (leading to its inactivation), involved in the CoQ10 synthesis led to aged oocytes in young mice with:
Premature ovarian failure
Reduction of follicle number
Poor ovulation response to stimulation
Decreased ATP production and mitochondrial activity in the few aged oocytes.
Altogether, these data suggest that a lack of CoQ10 could be responsible for a premature aging of the ovarian function with detrimental effects on oocyte quality. Most interestingly, CoQ10 supplementation could be used to counteract and even reverse the effects of aging on follicle development.
Indeed, a clinical trial has been led in women and showed interesting results. In the randomized, double-blind-study including IVF-ICSI patients between 35-43 years old, women were treated with either 600mg CoQ10 (N=17) or equivalent dose of placebo (N=22) for 2 months prior and during their IVF cycle (45). The rate of oocyte aneuploidy (using polar body biopsies) was 46.5% in the CoQ10 group compared to 62.8% in the controls. Clinical pregnancy rate was 33% for the CoQ10 group and 26.7% for the control group. Although, the difference was not significant due to the limited number of patients enrolled in the study, the data showed a trend towards oocyte improvement in CoQ10 treated patients.
In addition, levels of CoQ10 in the follicular fluid of N=20 infertile women correlate with oocyte maturation and embryo grade during in vitro fertilization (64). Another study (65) on N=60 patients undergoing ICSI showed that higher follicular fluid CoQ10 level were associated with grade A-B embryos (0.53 µg/mL) as compared to grade C-D embryos (0.39 µg/mL). Further, embryos leading to pregnancy were obtained from oocyte with higher follicular CoQ10 levels (0.6 µg/mL) when compared to those leading to failed implantation (0.38 µg/mL). Other studies have shown that low plasma CoQ10 levels correlates with subsequent spontaneous abortions (66).
CoQ10 and PCOS
Significantly lower fasting plasma glucose
Significantly lower serum insulin concentration
Significantly lower total cholesterol concentration
Significantly lower LDL-cholesterol concentration
Besides its beneficial effects on fertility, CoQ10 could also improve glucose metabolism and lipid profile in PCOS patients (67). A randomize, double-blind, placebo-controlled trial where patients were administrated with 100mg CoQ10 daily (N=30) or placebo (N=30) for 12 weeks showed that treated patients have:
So Overall, CoQ10 supplementation for 12 weeks among subjects with PCOS had beneficial effects on glucose metabolism, serum total- and LDL-cholesterol levels.
In PCOS patients (68) resistant to clomiphene citrate induction, CoQ10 could induce ovulation when combined to clomiphene citrate (N=51, 65.9% ovulation/cycle) as compared to controls (N=50 patients treated with clomiphene citrate alone, 15.5% ovulation/cycle) which leads to higher pregnancy rate per patient (37.3% vs 6%).
Lastly, CoQ10 reduces gamma glutamyltransferase, a specific enzyme involves in oxidative stress within 14 days of 150mg/day CoQ10 administration.
Altogether, these results are supportive of the usage of CoQ10 as a supplement in women fertility.
3- Pine tree Bark: pycnogenol
Pycnogenol® (PYC) is a plant extract obtained from the bark of the French maritime pine Pinus pinaster. It has strong antioxidant activity and is used as a phytochemical remedy for various diseases. In Vitro study in human lymphocytes showed its potent anti-oxidant potential as well as its abilities to reduce DNA damage and chromosome breakage induced by chemicals (69).Pycnogenol has been shown to exert anti-inflammatory and antithrombotic effects (70) by inhibiting Cox-1 and Cox-2 enzymatic activity (71), both involved in the inflammatory pathway. PYC is also able to significantly reduce pain associated with endometriosis, which is even reduced when combined with oral contraceptives after 3-months use (72). These effects are mediated through the suppression of NF-B-dependent gene expression, which activates the inflammatory cascade (73). In a study including N=58 patients affected by endometriosis and surgically diagnosed with the condition, the use of pycnogenol at 60mg/day for 48 weeks significantly reduced the symptoms score (N=26) as well as CA-125 levels (a serum marker of endometriosis) although in patients treated with hormones therapy (N=26), the benefits are even more pronounced.
Resveratrol is a polyphenolic compound isolated from the skin of red grapes and berries and found in red wine. In addition to its anti-inflammatory properties, it is a natural aromatase inhibitor (74), an enzyme involved in the synthesis of estradiol and has also antiproliferative and anti-oxidant properties (75).
Resveratrol and the ovarian function
In the ovary, resveratrol can activate a specific receptor and increases its expression, namely SIRT1 (76), present in oocyte and granulosa cells at different stages of the follicular development. The sirtuin pathway plays a key role in promoting mitochondrial biogenesis (77). This pathway is also involved in:
sensoring the oxidative stress levels in oocyte and granulosa cells
activating the steroidogenesis associated with luteinization (progesterone production)
repressing the pro-inflammatory NF-B pathway
repressing the synthesis of COX enzyme involved in prostaglandins production (pro-inflammatory pathway)
A recent mice study (78) showed that resveratrol promotes ovary and oocyte quality by interfering with a pesticide (mancozeb) used to induce accumulations of ROS (marker of oxidative stress). As a result, the abnormal mitochondrial function, the increased follicle apoptosis, the decreased development of mature oocyte is significantly minimized using resveratrol thus improving the reproductive outcomes. Similar effects were also reported in porcine oocytes cultured with resveratrol where mitochondrial functions including ATP generation were improved as well as the developmental ability of the oocytes to the blastocyst stages (79). In addition, resveratrol increased the ovarian follicular reserve and prolonged the ovarian life span in rats (80) by increasing AMH levels and reducing ovarian inflammation through SIRT1 regulation among other mechanisms, leading to the inhibition of the pro-inflammatory NF-B pathway.
Resveratrol and endometriosis
A recent and elegant study revealed that infertility related to endometriosis may be due to oocyte (egg) DNA damages induced by oxidative stress (81). Most importantly, the study further suggested that oxidative stress (the main cause of oocyte DNA damage) could be reversed using anti-oxidants such as resveratrol and melatonin thus rescuing the oocyte and leading to its development and maturation to give rise to a fertilizable egg.
To assess the effects of oxidative stress on oocyte development, the authors of the study exposed in vitro, immature healthy mouse oocyte to follicular fluid from women affected by endometriosis (ENDO-FF). They monitored the oocyte development and compared it to immature mouse oocyte cultured with follicular fluid from healthy women (controls patients not affected by endometriosis).
Results showed that Endo-FF induced:
Higher levels of ROS in the mouse oocyte
Higher levels of DNA damage in the mouse oocyte
Decrease or a delay in oocyte maturation as compared to controls
Oocyte maturation was impaired by Endo-FF and the oocytes’ development was blocked. Interestingly, the oocyte maturation was blocked at a very specific development stage (metaphase I arrest) where a sensor for DNA damage (Spindle Assembly Check point/DNA Damage Response) assesses the DNA integrity and blocks the oocyte maturation through the activation of a protein (ATM kinase).
The study showed that ROS directly activates this blocking protein to stop oocyte development.
Further, the authors showed that oocyte maturation could be rescued by inhibiting or lowering ROS levels using resveratrol and melatonin in the culture medium. It is very important to note that the noxious effects of ROS and pro-inflammatory factors presents in the follicular fluid of ENDO patients (such as IL-6, TNF-α) would be even more accentuated in human ovary where oocytes are exposed to follicular fluid at higher concentrations and for longer periods of time than in the current study.
In a mice model for endometriosis (82), endometriotic human implants were injected in the peritoneal cavity. Mice were treated by estradiol alone daily for 12 days (controls) or in combination with resveratrol daily for 20 days (controls). Mice were sacrificed and endometriotic lesions were assessed.
Results showed a 60% reduction in the number of lesions and an 80% reduction in the lesions’ volume in mice treated with resveratrol as compared to the control group (estradiol only). In the same study, in vitro investigations showed that resveratrol significantly reduce the invasiveness potential of human endometrial cells by up to 78%.
Besides confirming these results, another study run in rats (83-84) showed a significant decrease in pro-angiogenic factors such as VEGF at both serum and peritoneal fluid levels, but also a significant decrease in pro-inflammatory molecules such as MCP-1 in the peritoneal fluid and at the serum level. In addition, resveratrol-treated rats showed endometriotic lesions improvement (decreased number and volume) with significant decrease in oxidative stress (85) as shown by reduced activities of superoxide dismutase and glutathione peroxidase (two enzymes involved in the generation of oxidative stress).
Based on animal and In Vitro studies (86), resveratrol appears to be effective in counteracting the development of endometriosis through its antiangiogenic, anti-inflammatory properties, inhibiting the adhesion and proliferation of endometriotic lesions and reducing the oxidative stress.
Resveratrol and PCOS
The therapeutic potential of resveratrol in the treatment of PCOS has been postulated because this polyphenol promotes apoptosis (87) and reduces androgen synthesis (88) in ovarian theca cells.
A mice model for PCOS has been developed (ob/ob mice that are also leptin deficient), where mice are:
exhibiting increased TNF-a and IL-6 levels, which promotes the state of chronic low-grade inflammation.
A study (89) assessing the effects of resveratrol on metabolic parameters in ob/ob mice injected daily with resveratrol for 20 days or left untreated (as controls) showed that resveratrol:
reduces insulin levels
reduced TNF-α and IL-6 levels in adipose tissue
In a rat model for PCOS (90), daily intraperitoneal injection of resveratrol for 4 weeks induced:
a significant reduction in the number of antral follicle counts
a significantly decreased plasma anti-Mullerian hormone and insulin-like growth factor 1 levels (playing a key role in PCOS metabolic disturbances)
significantly lower superoxide dismutase activity
significantly increased glutathione peroxidase which will reduce cell vulnerability to ROS.
Altogether these data showed that resveratrol is effective in the treatment of PCOS through its antioxidant properties.
5- Green Formula: chlorella and spirulina
Reducing oxidative stress (ROS and free-radicals) in the oocyte is of prime clinical importance when treating sub-fertility in endometriosis patients or in any patients whose oocyte quality is affected by high levels of oxidative stress such as in PCOS or Correctible Reoccurring Aneuploid Conversion Syndrome or CRACS patients (For more information, read our blog on CRACS).
Our Greens formula has various therapeutic benefits as it is a rich source of nutrients, chlorophyll, phycocyanin, minerals, vitamin E and amino acids and is a precious asset to improve your fertility with:
anti-inflammatory effects and tolerogenic potential: many pro-inflammatory cytokines were shown to be suppressed while the generation of regulatory T cells has been promoted by our Green Formula’s ingredients.
Powerful scavenger of free-radicals: inhibiting oxidative stress by reducing ROS levels which decreases apoptosis of the growing follicles and improve your oocyte maturation and oocyte quality.
hypolipidemic activity: which is effective in improving the reproductive performance and minimizing the detrimental effects of diabetes on the oocyte quality.
To learn more about the benefits of our Green Formula on your fertility, read our blog.
As pioneer in the field of Reproductive Immunology, it is with the greatest care, that we studied any scientific evidences showing beneficial effects of these different ingredients on women fertility.
The Endo-Optimize supplement is the result of our work and has been developed to be the best solution to counteract oxidative stress induced-DNA damage. It optimizes your egg quality as well as minimizing your symptoms associated with endometriosis and PCOS.
This all in one pill contains many ingredients enhancing mitochondrial activity (a key component in oocyte development) and reducing inflammation thus allowing optimal microenvironment for the oocyte development and maturation.