Oxidative stress in male infertility and therapeutic approach: A mini-review

Abstract

Growing evidence suggests that oxidative stress is a major cause of male infertility. Spermatozoa are highly sensitive cells due to the vulnerability of their membrane fatty acids and the diminished antioxidant defense. Reactive oxygen species (ROS) impact multiple signaling pathways involved in mitochondrial dysfunction, hormonal unbalance and semen quality decline. The origin of ROS is diverse, including generated normal cellular metabolism, environmental exposure, advanced paternal age and inflammation. Research has indicated that antioxidant supplementation can improve oxidative stress and reduce the risk of chronic diseases. Moreover, it is widely known that antioxidant supplementation can enhance sperm quality and increase the pregnancy rate in couples undergoing fertility treatments. The current study highlights the deleterious effect of ROS and its impact on semen function. In addition, it contributes to the development of a clinical approach for the use of antioxidants in the management of male infertility.

Keywords

Oxidative stress / Reactive oxygen species / Mitochondria / Antioxidant supplementation / Spermatozoa

Conflict of interest statement

The authors declare no conflicts of interest to disclose.

Acknowledgements

We thank the editors for their positive feedback and hope that the revisions prompted by their comments have improved the manuscript.

Funding

The study received no extramural funding.

Authors’ contributions

Marwa Lahimer was in charge of writing the original draft; Henda Mustapha was responsible for visualization; Véronique Bach was in charge of visualization; Hafida Khorsi-Cauet, Moncef Benkhalifa, and Mounir Ajina were responsible for writing, review, editing, and supervision; Habib Ben Ali was in charge of writing, review, editing, and supervision.

Publisher's Note

The Publisher of the Journal remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

[1] Tremellen K. Oxidative stress and male infertility-A clinical perspective. Hum Reprod Update 2008; 14(3): 243-258. doi: 10.1093/humupd/dmn004.

[2] Aitken RJ, Drevet JR, Moazamian A, Gharagozloo P. Male infertility and oxidative stress: A focus on the underlying mechanisms. Antioxidants (Basel) 2022; 11(2): 306. doi: 10.3390/antiox11020306.

[3] Agarwal A, Parekh N, Panner Selvam MK, Henkel R, Shah R, Homa ST, et al. Male oxidative stress infertility (MOSI): Proposed terminology and clinical practice guidelines for management of idiopathic male infertility. World J Mens Health 2019; 37(3): 296-312. doi: 10.5534/wjmh.190055.

[4] Aitken RJ. Reactive oxygen species as mediators of sperm capacitation and pathological damage. Mol Reprod Dev 2017; 84(10): 1039-1052. doi: 10.1002/mrd.22871.

[5] Wu JQ, Kosten TR, Zhang XY. Free radicals, antioxidant defense systems, and schizophrenia. Progr Neuropsychopharmacol Biol Psychiat 2013; 46: 200-206. doi: 10.1016/j.pnpbp.2013.02.015.

[6] Pizzino G, Irrera N, Cucinotta M, Pallio G, Mannino F, Arcoraci V, et al. Oxidative stress: Harms and benefits for human health. Oxid Med Cell Longev 2017; 2017: 8416763. doi: 10.1155/2017/8416763.

[7] Wesselink E, Koekkoek WAC, Grefte S, Witkamp RF, van Zanten ARH. Feeding mitochondria: Potential role of nutritional components to improve critical illness convalescence. Clin Nutr 2019; 38(3): 982-995. doi: 10.1016/j.clnu.2018.08.032.

[8] Cui H, Kong Y, Zhang H. Oxidative stress, mitochondrial dysfunction, and aging. J Signal Transduct 2012; 2012: 646354. doi: 10.1155/2012/646354.

[9] Guo C, Sun L, Chen X, Zhang D. Oxidative stress, mitochondrial damage and neurodegenerative diseases. Neural Regen Res 2013; 8(21): 2003-2014. doi: 10.3969/j.issn.1673-5374.2013.21.009.

[10] Bashir P. Antioxidants: Reduces the male infertility. Pakistan J Med Health Sci 2023; 17(2): 114. doi: 10.53350/pjmhs2023172114.

[11] Almujaydil MS. The role of dietary nutrients in male infertility: A review. Life 2023; 13(2): 519. doi: 10.3390/life13020519.

[12] Ma L, Sun Y. Comparison of L-carnitine vs. Coq10 and vitamin E for idiopathic male infertility: A randomized controlled trial. Eur Rev Med Pharmacol Sci 2022; 26(13): 4698-4704. doi: 10.26355/eurrev_202207_29194.

[13] Alahmar AT. Coenzyme Q10 improves sperm motility and antioxidant status in infertile men with idiopathic oligoasthenospermia. Clin Exp Reprod Med 2022; 49(4): 277-284. doi: 10.5653/cerm.2022.05463.

[14] García-Rodríguez A, Gosálvez J, Agarwal A, Roy R, Johnston S. DNA damage and repair in human reproductive cells. Int J Mol Sci 2019; 20(1): 31. doi: 10.3390/ijms20010031.

[15] Cheng JB, Zhu J, Ni F, Jiang H. L-carnitine combined with coenzyme Q10 for idiopathic oligoasthenozoospermia: A double-blind randomized controlled trial. Zhonghua Nan Ke Xue 2018; 24(1): 33-38.

[16] Sicchieri F, Silva AB, Santana VP, Vasconcelos MAC, Ferriani RA, Vireque AA, et al. Phosphatidylcholine and L-acetyl-carnitine-based freezing medium can replace egg yolk and preserves human sperm function. Transl Androl Urol 2021; 10(1): 397-407. doi: 10.21037/tau-201004.

[17] Nateghian Z, Nasr-Esfahani MH, Talaei-Khozani T, Tavalaee M, Aliabadi E. L-carnitine and pentoxifylline supplementation improves sperm viability and motility at low temperature. Int J Fertil Steril 2023; 17(1): 61-66. doi: 10.22074/ijfs.2022.543872.1232.

[18] Lukaski HC. Low dietary zinc decreases erythrocyte carbonic anhydrase activities and impairs cardiorespiratory function in men during exercise. Am J Clin Nutr 2005; 81(5): 1045-1051. doi: 10.1093/ajcn/81.5.1045.

[19] Yang X, Wang H, Huang C, He X, Xu W, Luo Y, et al. Zinc enhances the cellular energy supply to improve cell motility and restore impaired energetic metabolism in a toxic environment induced by OTA. Sci Rep 2017; 7: 14669. doi: 10.1038/s41598-017-14868-x.

[20] Ziamajidi N, Khajvand-Abedini M, Daei S, Abbasalipourkabir R, Nourian A. Ameliorative effects of vitamins A, C, and E on sperm parameters, testis histopathology, and oxidative stress status in zinc oxide nanoparticle-treated rats. BioMed Res Int 2023; 2023: e4371611. doi: 10.1155/2023/4371611.

[21] Gomez-Cabrera MC, Domenech E, Romagnoli M, Arduini A, Borras C, Pallardo FV, et al. Oral administration of vitamin C decreases muscle mitochondrial biogenesis and hampers training-induced adaptations in endurance performance. Am J Clin Nutrit 2008; 87(1): 142-149. doi: 10.1093/ajcn/87.1.142.

[22] Jannatifar R, Asa E, Sahraei SS, Verdi A, Piroozmanesh H. N-acetyl-l-cysteine and alpha lipoic acid are protective supplement on human sperm parameters in cryopreservation of asthenoteratozoospermia patients. Androbgia 2022; 54(11): e14612. doi: 10.1111/and.14612.

[23] Jannatifar R, Parivar K, Roodbari NH, Nasr-Esfahani MH. Effects of N-acetyl-cysteine supplementation on sperm quality, chromatin integrity and level of oxidative stress in infertile men. Reprod Biol Endocrinol 2019; 17(1): 24. doi: 10.1186/s12958-019-0468-9.

[24] Agarwal A, Parekh N, Selvam MKP, Henkel R, Shah R, Homa ST, et al. Male oxidative stress infertility (MOSI): Proposed terminology and clinical practice guidelines for management of idiopathic male infertility. World J Mens Health 2019; 37(3): 296-312. doi: 10.5534/wjmh.190055.

[25] Zhang Q, Yin J, Zou Y. MiR-568 mitigated cardiomyocytes apoptosis, oxidative stress response and cardiac dysfunction via targeting SMURF2 in heart failure rats. Heart Vessels 2023; 38: 857-868. doi: 10.1007/s00380-022-02231-8.

[26] Ghafoor DD. Correlation between oxidative stress markers and cytokines in different stages of breast cancer. Cytokine 2023; 161: 156082. doi: 10.1016/j.cyto.2022.156082.

[27] Islam MdT. Oxidative stress and mitochondrial dysfunction-linked neurodegenerative disorders. Neurol Res 2017; 39(1): 73-82. doi: 10.1080/01616412.2016.1251711.

[28] Wang X, Wang W, Li L, Perry G, Lee H, Zhu X. Oxidative stress and mitochondrial dysfunction in Alzheimer's disease. Biochim Biophys Acta (BBA)-Mol Basis Dis 2014; 1842(8): 1240-1247. doi: 10.1016/j.bbadis.2013.10.015.

[29] Altun S, Özdemir S, Arslan H. Histopathological effects, responses of oxidative stress, inflammation, apoptosis biomarkers and alteration of gene expressions related to apoptosis, oxidative stress, and reproductive system in chlorpyrifos-exposed common carp (Cyprinus carpio L.). Environ Pollut 2017; 230: 432-443. doi: 10.1016/j.envpol.2017.06.085.

[30] Lahimer M, Capelle S, Lefranc E, Cabry R, Montjean D, Bach V, et al. Effect of pesticide exposure on human sperm characteristics, genome integrity, and methylation profile analysis. Environ Sci Pollut Res Int 2023; 30(31): 77560-77567. doi: 10.1007/s11356-023-27695-7.

[31] Lahimer M, Montjean D, Cabry R, Capelle S, Lefranc E, Bach V, et al. Paternal age matters: Association with sperm criteria's- spermatozoa DNA integrity and methylation profile. J Clin Med 2023; 12(15): 4928. doi: 10.3390/jcm12154928.

[32] Aitken RJ. Male reproductive ageing: A radical road to ruin. Hum Reprod 2023; 38(10): 1861-1871. doi: 10.1093/humrep/dead157.

[33] Nita M, Grzybowski A. The role of the reactive oxygen species and oxidative stress in the pathomechanism of the age-related ocular diseases and other pathologies of the anterior and posterior eye segments in adults. Oxid Med Cell Longev 2016; 2016: 3164734. doi: 10.1155/2016/3164734.

[34] Das K, Roychoudhury A. Reactive oxygen species (ROS) and response of antioxidants as ROS-scavengers during environmental stress in plants. Front Environ Sci 2014; 2. doi: 10.3389/fenvs.2014.00053.

[35] Dröge W. Free radicals in the physiological control of cell function. Physiol Rev 2002; 82(1): 47-95. doi: 10.1152/physrev.00018.2001.

[36] Juan CA, Pérez de la Lastra JM, Plou FJ, Pérez-Lebeña E. The chemistry of reactive oxygen species (ROS) revisited: Outlining their role in biological macromolecules (DNA, lipids and proteins) and induced pathologies. Int J Mol Sci 2021; 22(9): 4642. doi: 10.3390/ijms22094642.

[37] Magnani F, Mattevi A. Structure and mechanisms of ROS generation by NADPH oxidases. Curr Opin Struct Biol 2019; 59: 91-97. doi: 10.1016/j.sbi.2019.03.001.

[38] Khan M, Ali S, Al Azzawi TNI, Saqib S, Ullah F, Ayaz A, et al. The key roles of ROS and RNS as a signaling molecule in plant-microbe interactions. Antioxidants 2023; 12(2): 268. doi: 10.3390/antiox12020268.

[39] Rizwan H, Kumar S, Kumari G, Pal A. High glucose-induced increasing reactive nitrogen species accumulation triggered mitochondrial dysfunction, inflammation, and apoptosis in keratinocytes. Life Sci 2023; 312: 121208. doi: 10.1016/j.lfs.2022.121208.

[40] Lamaudière MTF, Arasaradnam R, Weedall GD, Morozov IY. The colorectal cancer microbiota alter their transcriptome to adapt to the acidity, reactive oxygen species, and metabolite availability of gut microenvironments. mSphere 2023; 8(2): e0062722. doi: 10.1128/msphere.00627-22.

[41] Aitken RJ, West K, Buckingham D. Leukocytic infiltration into the human ejaculate and its association with semen quality, oxidative stress, and sperm function. J Androl 1994; 15(4): 343-352. doi: 10.1002/j.19394640.1994.tb00462.x.

[42] Becatti M, Cito G, Argento FR, Fini E, Bettiol A, Borghi S, et al. Blood leukocyte ROS production reflects seminal fluid oxidative stress and spermatozoa dysfunction in idiopathic infertile men. Antioxidants 2023; 12(2): 479. doi: 10.3390/antiox12020479.

[43] Koppers AJ, De Iuliis GN, Finnie JM, McLaughlin EA, Aitken RJ. Significance of mitochondrial reactive oxygen species in the generation of oxidative stress in spermatozoa. J Clin Endocrinol Metab 2008; 93(8): 3199-3207. doi: 10.1210/jc.2007-2616.

[44] Zhang H, Liu H, Kataoka S, Kinukawa M, Uchiyama K, Kambe J, et al. L-amino acid oxidase 1 in sperm is associated with reproductive performance in male mice and bulls. Biol Reprod 2021; 104(5): 1154-1161. doi: 10.1093/biolre/ioab024.

[45] Minas A, Razi M, Nasr-Esfahani MH, Hashemi-Asl SM, Tavalaee M. Oxidative stress and cell cycle arrest in seminiferous tubules nearby varicose vessels: New perspectives from experimental varicocele. Reprod Sci 2023; 30(8): 2401-2415. doi: 10.1007/s43032-023-01200-4.

[46] Sharifi-Rad M, Anil Kumar NV, Zucca P, Varoni EM, Dini L, Panzarini E, et al. Lifestyle, oxidative stress, and antioxidants: Back and forth in the pathophysiology of chronic diseases. Front Physiol 2020; 11: 694. doi: 10.3389/fphys.2020.00694.

[47] Tosic J, Walton A. Formation of hydrogen peroxide by spermatozoa and its inhibitory effect on respiration. Nature 1946; 158(4014): 485-485. doi: 10.1038/158485a0.

[48] Ko EY, Sabanegh ES, Agarwal A. Male infertility testing: Reactive oxygen species and antioxidant capacity. Fertil Steril 2014; 102(6): 1518-1527. doi: 10.1016/j.fertnstert.2014.10.020.

[49] Roychoudhury S, Chakraborty S, Choudhury AP, Das A, Jha NK, Slama P, et al. Environmental factors-induced oxidative stress: Hormonal and molecular pathway disruptions in hypogonadism and erectile dysfunction. Antioxidants 2021; 10(6): 837. doi: 10.3390/antiox10060837.

[50] Guerriero G, Trocchia S, Abdel-Gawad FK, Ciarcia G. Roles of reactive oxygen species in the spermatogenesis regulation. Front Endocrinol (Lausanne) 2014; 5: 56. doi: 10.3389/fendo.2014.00056.

[51] Hussain T, Kandeel M, Metwally E, Murtaza G, Kalhoro DH, Yin Y, et al. Unraveling the harmful effect of oxidative stress on male fertility: A mechanistic Insight. Front Endocrinol (Lausanne) 2023; 14: 1070692. doi: 10.3389/fendo.2023.1070692.

[52] Dutta S, Sengupta P, Roychoudhury S, Chakravarthi S, Wang CW, Slama P. Antioxidant paradox in male infertility: ‘A blind eye’ on inflammation. Antioxidants (Basel) 2022; 11(1): 167. doi: 10.3390/antiox11010167.

[53] Dutta S, Sengupta P, Slama P, Roychoudhury S. Oxidative stress, testicular inflammatory pathways, and male reproduction. Int J Mol Sci 2021; 22(18): 10043. doi: 10.3390/ijms221810043.

[54] Ignatiuk V, Izvolskaia M, Sharova V, Zakharova L. Disruptions in hypothalamic-pituitary-gonadal axis development and their IgG modulation after prenatal systemic inflammation in male rats. Int J Mol Sci 2023; 24(3): 2726. doi: 10.3390/ijms24032726.

[55] Darbandi M, Darbandi S, Agarwal A, Sengupta P, Durairajanayagam D, Henkel R, et al. Reactive oxygen species and male reproductive hormones. Reprod Biol Endocrinol 2018; 16(1): 87. doi: 10.1186/s12958018-0406-2.

[56] Xie Q, Kang Y, Zhang C, Xie Y, Wang C, Liu J, et al. The role of kisspeptin in the control of the hypothalamic-pituitary-gonadal axis and reproduction. Front Endocrinol (Lausanne) 2022; 13: 925206. doi: 10.3389/fendo.2022.925206.

[57] Vallet-Buisan M, Mecca R, Jones C, Coward K, Yeste M. Contribution of semen to early embryo development: Fertilization and beyond. Hum Reprod Update 2023; 29(4): 395-433. doi: 10.1093/humupd/dmad006.

[58] Chaudhry R, Varacallo M. Biochemistry, glycolysis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.

[59] Alabduladhem TO, Bordoni B. Physiology, Krebs cycle. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.

[60] Ahmad M, Wolberg A, Kahwaji CI. Biochemistry, Electron transport chain. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022.

[61] Vo TD, Greenberg HJ, Palsson BO. Reconstruction and functional characterization of the human mitochondrial metabolic network based on proteomic and biochemical data. J Biol Chem 2004; 279(38): 39532-39540. doi: 10.1074/jbc.M403782200.

[62] Kühlbrandt W. Structure and function of mitochondrial membrane protein complexes. BMC Biol 2015; 13(1): 89. doi: 10.1186/s12915-0150201-x.

[63] Velando A, Noguera JC, da Silva A, Kim SY. Redox-regulation and life-history trade-offs: Scavenging mitochondrial ROS improves growth in a wild bird. Sci Rep 2019; 9(1): 2203. doi: 10.1038/s41598-019-38535-5.

[64] Hayakawa M, Ogawa T, Sugiyama S, Tanaka M, Ozawa T. Massive conversion of guanosine to 8-hydroxy-guanosine in mouse liver mitochondrial DNA by administration of azidothymidine. Biochem Biophys Res Commun 1991; 176(1): 87-93. doi: 10.1016/0006291X(91)90893-C.

[65] Barati E, Nikzad H, Karimian M. Oxidative stress and male infertility: Current knowledge of pathophysiology and role of antioxidant therapy in disease management. Cell Mol Life Sci 2020; 77(1): 93-113. doi: 10.1007/s00018-019-03253-8.

[66] Richter C. Reactive oxygen and DNA damage in mitochondria. Mutat Res 1992; 275(3): 249-255. doi: 10.1016/0921-8734(92)90029-O.

[67] Salminen A, Ojala J, Kaarniranta K, Kauppinen A. Mitochondrial dysfunction and oxidative stress activate inflammasomes: Impact on the aging process and age-related diseases. Cell Mol Life Sci 2012; 69(18): 2999-3013. doi: 10.1007/s00018-012-0962-0.

[68] Elfawy HA, Das B. Crosstalk between mitochondrial dysfunction, oxidative stress, and age related neurodegenerative disease: Etiologies and therapeutic strategies. Life Sci 2019; 218: 165-184. doi: 10.1016/j.lfs.2018.12.029.

[69] Smaili SS, Hsu YT, Carvalho ACP, Rosenstock TR, Sharpe JC, Youle RJ. Mitochondria, calcium and pro-apoptotic proteins as mediators in cell death signaling. Braz J Med Biol Res 2003; 36(2): 183-190. doi: 10.1590/S0100-879X2003000200004.

[70] Matuz-Mares D, González-Andrade M, Araiza-Villanueva MG, Vilchis-Landeros MM, Vázquez-Meza H. Mitochondrial calcium: Effects of its imbalance in disease. Antioxidants (Basel) 2022; 11(5): 801. doi: 10.3390/antiox11050801.

[71] Alahmar AT. Role of oxidative stress in male infertility: An updated review. J Hum Reprod Sci 2019; 12(1): 4-18. doi: 10.4103/jhrs.JHRS_150_18.

[72] Jones R, Mann T, Sherins R. Peroxidative breakdown of phospholipids in human spermatozoa, spermicidal properties of fatty acid peroxides, and protective action of seminal plasma. Fertil Steril 1979; 31(5): 531-537. doi: 10.1016/s0015-0282(16)43999-3.

[73] Kurkowska W, Bogacz A, Janiszewska M, Gabry E, Tiszler M, Bellanti F, et al. Oxidative stress is associated with reduced sperm motility in normal semen. Am J Mens Health 2020; 14(5): 1557988320939731. doi: 10.1177/1557988320939731.

[74] Nowicka-Bauer K, Nixon B. Molecular changes induced by oxidative stress that impair human sperm motility. Antioxidants 2020; 9(2): 134. doi: 10.3390/antiox9020134.

[75] Kehm R, Baldensperger T, Raupbach J, Höhn A. Protein oxidation-Formation mechanisms, detection and relevance as biomarkers in human diseases. Redox Biol 2021; 42: 101901. doi: 10.1016/j.redox.2021.101901.

[76] Milkovic L, Cipak Gasparovic A, Cindric M, Mouthuy PA, Zarkovic N. Short overview of ROS as cell function regulators and their implications in therapy concepts. Cells 2019; 8(8): 793. doi: 10.3390/cells8080793.

[77] Omari Shekaftik S, Nasirzadeh N. 8-hydroxy-2’-deoxyguanosine (8-OHdG) as a biomarker of oxidative DNA damage induced by occupational exposure to nanomaterials: A systematic review. Nanotoxicology 2021; 15(6): 850-864. doi: 10.1080/17435390.2021.1936254.

[78] Noblanc A, Damon-Soubeyrand C, Karrich B, Henry-Berger J, Cadet R, Saez F, et al. DNA oxidative damage in mammalian spermatozoa: Where and why is the male nucleus affected? Free Radical Biol Med 2013; 65: 719-723. doi: 10.1016/j.freeradbiomed.2013.07.044.

[79] Rosa AC, Corsi D, Cavi N, Bruni N, Dosio F. Superoxide dismutase administration: A review of proposed human uses. Molecules 2021; 26(7): 1844. doi: 10.3390/molecules26071844.

[80] Park MK, Choi BY, Kho AR, Lee SH, Hong DK, Kang BS, et al. The protective role of glutathione on zinc-induced neuron death after brain injuries. Int J Mol Sci 2023; 24(3): 2950. doi: 10.3390/ijms24032950.

[81] Kaushal J, Mehandia S, Singh G, Raina A, Arya SK. Catalase enzyme: Application in bioremediation and food industry. Biocatal Agric Biotechnol 2018; 16: 192-199. doi: 10.1016/j.bcab.2018.07.035.

[82] Wesselink E, Koekkoek WAC, Grefte S, Witkamp RF, van Zanten ARH. Feeding mitochondria: Potential role of nutritional components to improve critical illness convalescence. Clin Nutr 2019; 38(3): 982-995. doi: 10.1016/j.clnu.2018.08.032.

[83] Depeint F, Bruce WR, Shangari N, Mehta R, O’Brien PJ. Mitochondrial function and toxicity: Role of the B vitamin family on mitochondrial energy metabolism. Chem-Biol Interact 2006; 163(1): 94-112. doi: 10.1016/j.cbi.2006.04.014.

[84] Carlsen E, Giwercman A, Keiding N, Skakkebaek NE. Evidence for decreasing quality of semen during past 50 years. BMJ 1992; 305(6854): 609-613. doi: 10.1136/bmj.305.6854.609.

[85] Micic S, Lalic N, Djordjevic D, Bojanic N, Bogavac-Stanojevic N, Busetto GM, et al. Double-blind, randomised, placebo-controlled trial on the effect of L-carnitine and L-acetylcarnitine on sperm parameters in men with idiopathic oligoasthenozoospermia. Andrologia 2019; 51(6): e13267. doi: 10.1111/and.13267.

[86] Scaruffi P, Licata E, Maccarini E, Massarotti C, Bovis F, Sozzi F, et al. Oral antioxidant treatment of men significantly improves the reproductive outcome of IVF cycles. J Clin Med 2021; 10(15): 3254. doi: 10.3390/jcm10153254.

[87] Li K, Yang X, Wu T. The effect of antioxidants on sperm quality parameters and pregnancy rates for idiopathic male infertility: A network meta-analysis of randomized controlled trials. Front Endocrinol 2022; 13. doi: 10.3389/fendo.2022.810242.