Hippo signaling disruption and ovarian follicle activation in infertile patients

Fertil Steril. 2020 Sep;114(3):458-464. doi: 10.1016/j.fertnstert.2020.07.031. Epub 2020 Aug 8.


The Hippo signaling pathway, which is important in organ size regulation, is present in organisms from the fly to mammals. Disruption of the Hippo signaling pathway leads to increased nuclear translocation of the effector Yes-associated protein (YAP), resulting in the expression of cystein-rich 61, connective tissue growth factor, and nephroblastoma overexpressed (CCN) growth factors and baculoviral inhibitors of apoptosis repeat containing (BIRC) apoptosis inhibitors to increase organ sizes. Furthermore, genome-wide knockdown of genes in insect cells demonstrated that actin polymerization promoted nuclear translocation of YAP. In the mammalian ovary, we demonstrated the expression of Hippo signaling pathway genes and showed that ovarian fragmentation increased actin polymerization, leading to YAP nuclear translocation and increased expression of cystein-rich 61, CCN growth factors and BIRC apoptosis inhibitors, followed by enhanced follicle growth. Here we summarize evidence suggesting the role of mechanical stress on follicle growth in the ovary and describe recent use of ovary-damaging procedures to treat ovarian infertility. Ovarian fragmentation, together with in vitro incubation with Akt-stimulating drugs, formed the basis of an in vitro activation (IVA) therapy to treat patients with premature ovarian insufficiency, whereas ovarian fragmentation alone (drug-free IVA) was successful in treating patients with premature ovarian insufficiency with recent menses cessation. For middle-aged women with poor ovarian responses and diminished ovarian reserve, drug-free IVA was also effective in promoting follicle growth for infertility treatment. In addition, an in vivo follicle activation approach based on laparoscopic ovarian incision showed promise for patients with resistant ovary syndrome. With initial success using mechanical disruption approaches, future investigation could evaluate possibilities to refine mechanical methods and to locally administer actin polymerization-enhancing drugs for ovarian infertility treatment.

Keywords: Hippo signaling; diminished ovarian reserve; drug-free IVA; ovary; premature ovarian insufficiency.

Publication types

  • Review

MeSH terms

  • Female
  • Fertility Agents, Female / therapeutic use
  • Hippo Signaling Pathway
  • Humans
  • Infertility, Female / metabolism
  • Infertility, Female / physiopathology
  • Infertility, Female / therapy*
  • Ovarian Follicle / drug effects
  • Ovarian Follicle / metabolism*
  • Ovarian Follicle / physiopathology
  • Ovarian Reserve* / drug effects
  • Ovulation* / drug effects
  • Pregnancy
  • Primary Ovarian Insufficiency / metabolism
  • Primary Ovarian Insufficiency / physiopathology
  • Primary Ovarian Insufficiency / therapy*
  • Protein Serine-Threonine Kinases / metabolism*
  • Reproductive Techniques, Assisted*
  • Signal Transduction
  • Stress, Mechanical


  • Fertility Agents, Female
  • Protein Serine-Threonine Kinases