Integrated Metabolomic and Transcriptomic Profiling Reveals a Distinct Pathological Aging State in Diminished Ovarian Reserve of Advanced Reproductive-Age Women

Women of advanced age exhibit significant heterogeneity in ovarian reserve, categorized as normal (NOR) or diminished (DOR). This study aims to distinguish physiological age-related decline from pathological accelerated aging in DOR, and to explore underlying molecular mechanisms for optimizing assisted reproductive strategies. In vitro fertilization-embryo transfer (IVF-ET) outcomes were retrospectively compared in advanced-age women (≥ 40 years) with NOR or DOR treated at our center (January 2022 - December 2024). Simultaneously, follicular fluid (FF) was collected from both groups (n = 20). After centrifugation, metabolomic analysis was performed on metabolites, and transcriptomic sequencing on isolated granulosa cells (GCs). Despite comparable fertilization and cleavage-stage embryo quality, the DOR group showed significantly lower rates of oocyte maturation, blastocyst formation, clinical pregnancy, and live birth (P < 0.05). Metabolomic analysis revealed 28 differential metabolites (DMs) in FF, primarily enriched in galactose metabolism. Transcriptomics of GCs identified 246 differentially expressed mRNAs (DEmRNAs), prominently enriched in immune-related pathways. Protein-protein interaction analysis highlighted five hub genes (CX3CR1, CD69, FCER1A, EOMES, SPRR2A). Integrated analysis of the top 50 DEmRNAs with the top 400 DEmRNA-DM correlation pairs identified five key genes-IGLC3, RNVU1-29, FAM110C, NPY2R, and KCNN4-bridging GC transcriptome and FF metabolome, with key pairs including RNVU1-29 with lysylhydroxyproline and a sterane derivative, and FAM110C with 16-hydroxyhexadecanoic acid. In conclusion, DOR in advanced age may represent a distinct pathological aging state characterized by a dysregulated follicular microenvironment potentially shaped by immune activation and metabolic reprogramming. The identified key gene-metabolite pairs offer candidate molecular links to compromised oocyte developmental competence.