Combination antiretroviral therapy has transformed HIV from a fatal infection into a manageable chronic condition for roughly 41 million people worldwide, most of them in sub-Saharan Africa, where Nigeria carries one of the heaviest burdens with about two million infected individuals. The World Health Organization recommends TLD as the standard first-line regimen: two nucleotide or nucleoside reverse transcriptase inhibitors that block viral replication, paired with dolutegravir, an integrase strand transfer inhibitor that prevents viral DNA from inserting into the host genome. Although the therapy suppresses the virus, restores immune function, and reduces opportunistic infections, clinicians have increasingly observed that women living with HIV may experience earlier decline in ovarian function, more menstrual abnormalities, and earlier menopause than HIV-negative women. Whether these disturbances stem from the virus itself or from the drugs has remained an open question.

To probe that question, researchers at the University of Lagos and the Medical University of Vienna turned to a two-pronged design. In the experimental arm, fifteen adult female Wistar rats with established estrous cycles were randomized into three groups of five. One group received distilled water as a control, a second received TLD-based therapy at 22 milligrams per kilogram of body weight—a weight-based conversion of the standard 650-milligram fixed-dose combination pill—and a third received dolutegravir alone at 2.5 milligrams per kilogram. All drugs were given orally once daily for 28 consecutive days, a duration consistent with the OECD test guideline 407 for repeated-dose toxicity, and the doses were deliberately chosen to mimic minimal therapeutic exposure rather than overdose conditions.

The results were striking even at these low doses. Daily microscopic examination of vaginal smears revealed that both treated groups spent significantly longer in the diestrus phase of the estrous cycle—the resting phase between ovulations—and significantly fewer days in metestrus, a pattern indicative of impaired ovulatory function. The number of ovulated ova recovered from the fallopian tubes fell sharply in both treated groups compared with controls, with p-values of 0.0002 for the combination therapy group and 0.0003 for the dolutegravir-only group. Under the microscope, ovarian sections from treated animals showed atretic follicles, distorted antral follicles, degenerate nuclei, vascular congestion, and sparsely distributed theca and granulosa cells, all hallmarks of follicular degeneration and disordered folliculogenesis.

Biochemical assays of ovarian tissue pointed to oxidative stress as a central mechanism. The combination-treated animals showed significantly elevated malondialdehyde, a lipid peroxidation product that marks oxidative damage to cell membranes, alongside significantly depleted glutathione and reduced catalase activity, two of the tissue’s principal antioxidant defenses. The authors propose that the nucleoside reverse transcriptase inhibitors contribute substantially to this oxidative burden by inhibiting mitochondrial DNA polymerase-gamma, which depletes mitochondrial DNA, impairs oxidative phosphorylation, drains cellular ATP, and generates excess reactive oxygen species. Granulosa cells are exceptionally dependent on mitochondrial energy production for follicular maturation and steroidogenesis, making them particularly vulnerable to this kind of metabolic injury. Dolutegravir, for its part, has been shown in cellular models to alter mitochondrial membrane potential and increase reactive oxygen species, and recent work has also linked it to endoplasmic reticulum stress at the blood-brain barrier, suggesting that disturbances of intracellular protein and metabolic homeostasis may amplify the oxidative cascade.

The endocrine data reinforced the picture of a disrupted hypothalamic-pituitary-ovarian axis. Serum follicle-stimulating hormone and luteinizing hormone—the pituitary signals that drive follicle development and ovulation—were significantly reduced in both treated groups, with the combination regimen producing the stronger suppression. The authors suggest a plausible inflammatory route for this suppression: mitochondrial stress and excess reactive oxygen species activate the NF-kappa-B pathway and the NLRP3 inflammasome, promoting pro-inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-6. Patients on long-term antiretroviral therapy have been shown to carry persistent elevations of these cytokines, which are known to suppress hypothalamic gonadotropin-releasing hormone pulsatility and reduce pituitary responsiveness, ultimately lowering downstream LH and FSH secretion. The greater suppression seen with the full combination suggests that tenofovir and lamivudine add to the burden imposed by dolutegravir alone, consistent with a model in which reproductive toxicity arises from cumulative mitochondrial and oxidative stress across multiple drugs rather than from any single agent.

The clinical arm of the study, though small, lent human relevance to these mechanisms. Twenty women living with HIV, all aged 40 or younger and all taking TLD-based therapy for at least twelve months, were recruited from the AIDS Prevention Initiative of Nigeria clinic at Lagos University Teaching Hospital. Serum anti-Müllerian hormone, produced by granulosa cells of growing follicles and widely regarded as the most reliable biomarker of functional ovarian reserve, was measured with a sandwich ELISA. Ten of the twenty participants—50 percent—had AMH values below 1.0 nanogram per milliliter, falling into the low or very low categories, and eleven—55 percent—fell below the 1.5 nanogram per milliliter threshold that the study classified as the floor of the normal range. Notably, menstrual patterns were largely preserved: 90 percent of participants had normal flow duration, and menstrual interval and dysmenorrhea showed no significant changes, suggesting that overt menstrual disruption may lag well behind underlying follicular depletion.

The dissociation between preserved menstruation and reduced ovarian reserve carries implications that extend beyond fertility. Low AMH in this population may serve as a systemic marker of accelerated biological aging: prior work has shown that women living with HIV exhibit shorter leukocyte telomere length, a hallmark of cellular senescence that correlates with prematurely low AMH. Epidemiological studies have also linked low AMH in reproductive age to a two-fold increased risk of metabolic dysfunction-associated steatotic liver disease, while women with that liver condition transition to menopause earlier. Depletion of the follicle pool also erodes estrogen’s cardioprotective effects, raising the possibility of elevated cardiovascular risk, although estradiol was not directly assayed in this study. The authors caution that these broader outcomes were not measured here and remain hypotheses for future research.

The study has clear limitations that temper its conclusions. The 28-day animal exposure cannot replicate the chronic, often lifelong treatment that women living with HIV receive, and it remains unknown whether the observed ovarian effects are reversible or progressive over years. The clinical cohort of twenty participants, without a control group, introduces variability in AMH measurements and limits statistical power, and the design cannot disentangle the effects of HIV infection itself from those of the drug regimen. The authors did not adjust for nutritional status, socioeconomic factors, or viral suppression levels, all of which could influence reproductive hormones. They recommend future studies comparing HIV-negative women, HIV-positive women on alternative regimens, and HIV-positive women on TLD, adequately powered for age, duration of infection, and disease severity.

Importantly, the researchers stop short of recommending any change to clinical practice. The exploratory nature of the AMH findings is insufficient to justify routine AMH screening or modification of standard TLD-based therapy, which remains a highly effective and well-tolerated regimen that has saved millions of lives. What the study does argue for is attention: reproductive health and future fertility should remain part of clinical counseling for women of reproductive age on long-term antiretroviral therapy, with individualized assessment where clinically appropriate. As the population of women receiving lifelong TLD continues to grow, longitudinal and adequately controlled studies will be essential to determine whether the subtle ovarian changes documented here translate into meaningful fertility and health consequences over decades of treatment.

Subject of Research: Effects of TLD-based antiretroviral therapy on ovarian function and reserve

Article Title: TLD-Based Antiretroviral Therapy Compromises Ovarian Function and Reserve: Evidence from Experimental and Clinical Studies

Article References: Ugwu, M., Bakare, A. A., Nafiu, T., Dosumu, O. O., & Akang, E. N. (2026). TLD-Based Antiretroviral Therapy Compromises Ovarian Function and Reserve: Evidence from Experimental and Clinical Studies. Reproductive Sciences. https://doi.org/10.1007/s43032-026-02229-x

Image Credits: AI Generated

DOI: 10.1007/s43032-026-02229-x

Keywords: HIV, antiretroviral therapy, dolutegravir, tenofovir, lamivudine, ovarian reserve, anti-Müllerian hormone, oxidative stress, fertility, reproductive health, mitochondrial toxicity, women's health