ANALYTICAL AND QUANTITATIVE CYTOPATHOLOGY AND HISTOPATHOLOGY

1. 85
OBJECTIVE: Ovarian torsion is a condition that affects
the development of ovaries and restricts blood flow. It
occurs most frequently in women of reproductive age,
and delay in torsion resolution may result in necrosis
and ovarian loss. Ischemia-reperfusion of ovarian tis­
sue is known to cause oxidative damage. We aimed to
investigate caspase-3 expression as it is involved in
apoptosis and inflammation, and sFlt-1 which is re-
sponsible for endothelial dysfunction produced by vari­
ous tissues.
STUDY DESIGN: Wistar female rats (n=32) were ran­
domly divided into 4 groups: control, ischemia, ischemia-
reperfusion, and ischemia-reperfusion+simvastatin. In
the control group, the ovaries were surgically opened
and closed, then blood and ovarian tissues of the animals
were taken. In the ischemia and ischemia-reperfusion
groups, the ovaries were surgically opened, and the
left ovaries were sealed for ischemia. After 2 hours of
ischemia, blood flow was re-allowed for 2.5 hours of
reperfusion. In the ischemia-reperfusion group treated
with simvastatin (10 mg/kg), rats were given simva-
statin orally after reperfusion, and blood and tissue
specimens were taken after 3 hours. Malondialdehyde
(MDA) levels and glutathione peroxidase (GSH-Px)
activities were determined in the ovarian tissue homog­
enates for each rat.
RESULTS: In the simvastatin-administered group,
MDA and GSH values decreased as compared to in
the ischemia and ischemia-reperfusion groups. In the
simvastatin-treated group, GSH values were increased.
In the ischemia group, degenerated granular cells in
the antral follicle, luteal cells in the corpus luteum, and
intense inflammatory cells in the stromal region were
positive for expression of caspase-3. In the ischemia-
reperfusion group, caspase-3 expression was positive
in oocyte, granular, and stromal cells. In the ischemia-
reperfusion+simvastatin–treated group, caspase-3 ex-
pression was negative in the granular cells of the
antral follicle. It was positive in some stromal cells and
corpus luteum cells. In the ischemia-reperfusion group,
there was an increase in the expression of sFlt-1 in the
luteal cells of the corpus luteum and in the vascular
endothelial and inflammatory cells. In the ischemia-
reperfusion+simvastatin–treated group, follicle cells and
Analytical and Quantitative Cytopathology and Histopathology®
0884-6812/20/4203-0085/$18.00/0 © Science Printers and Publishers, Inc.
Analytical and Quantitative Cytopathology and Histopathology®
Simvastatin Treatment Prevents Cell Damage
and Regulates Angiogenesis in a Rat Ovarian
Torsion and Detorsion Model
An Immunohistochemical Study of Caspase-3 and sFlt-1
Expression
Cihan Toğrul, M.D., and Engin Deveci, Ph.D.
From the Department of Gynecology and Obstetrics, Hitit University Medical School, Çorum; and the Department of Histology and
Embryology, Dicle University Medical School, Diyarbakır, Turkey.
Cihan Toğrul is Associate Professor, Department of Gynecology and Obstetrics, Hitit University Medical School.
Engin Deveci is Professor, Department of Histology and Embryology, Dicle University Medical School.
Address correspondence to: Engin Deveci, Ph.D., Department of Histology and Embryology, Dicle University Medical School, Univer­
sity Street, Diyarbakır 21280, Turkey (engindeveci64@gmail.com).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.

2. cells in the corpus luteum showed decreased sFlt-1
expression, whereas sFlt-1 expression was positive in
vascular endothelial cells.
CONCLUSION: We suggest that simvastatin admin­
istration could prevent cell damage by affecting pro­
apoptosis activation. Simvastatin administration may
induce the regulation of angiogenesis. (Anal Quant
Cytopathol Histpathol 2020;42:85–94)
Keywords: apoptosis; immunohistochemistry; ne-
crosis; ovarian diseases; ovarian torsion; ovary;
rats, Wistar; reperfusion injury; simvastatin; tor-
sion abnormality; torsion-detorsion.
Ovarian torsion is a vascular occlusion condition
that adversely affects the development of ovaries
and restricts blood flow. Ovarian torsion accounts
for approximately 3% of gynecological emergen­
cies and occurs most frequently in women of
reproductive age. Delay in torsion resolution may
result in necrosis and ovarian loss.1 Ischemia-
reperfusion injury is defined as a major cause of
ovarian tissue damage caused by torsion and de-
torsion.
Although reperfusion largely restores ischemic
tissue to normal functional tissue, it does harm
to the tissue. Inflammatory response by reperfu­
sion is associated with complementary and poly­
morphonuclear leukocyte (PMNL)–endothelial ac-
tivation. If inflammatory response occurs at the
site of the reperfusion, many cytokines, chemo-
kines, and proinflammatory metabolites are re-
leased through the site.2
MDA formed by lipid peroxidation causes
cross-linking and polymerization of membrane
structures. This event changes the intrinsic mem­
brane properties such as deformation, ion tran­
sport, enzyme activity, and aggregation of cell
surface components. MDA levels were measured
in ovarian tissue to determine and confirm the de-
gree of ischemia-reperfusion injury. Ovarian tissue
MDA levels in the ischemia-reperfusion groups
were higher than those in the control groups. This
result suggests that ischemia reperfusion causes
oxidative damage in the ovarian tissue and causes
lipid peroxidation.3
Caspases are a family of genes maintaining
homeostasis through regulating cell death and in-
flammation. They participate in ordered processes
such as apoptosis and inflammation. Caspases
are classified according to their roles in apopto­
sis; caspase-3 acts as an executioner caspase.4 A
study showed caspase-3 expression in granulosa
cells from human ovarian tissue, suggesting that
caspase-3 activation plays a role in the formation
of apoptotic cell death. They observed apoptotic
morphological features such as DNA fragmenta-
tion in granulosa cells of ovarian follicles.5
Vascular endothelial growth factor–A (VEGF-A),
a member of vascular endothelial growth factor,
induces endothelial cell proliferation and increases
endothelial cell permeability.6 VEGF regulates three
tyrosine kinase family receptors (Flt-1, KDR/Flk-1,
and Flt-4) and binds only two receptors, KDR and
Flt-1, with a high affinity.7 Soluble fms-like tyro­
sine kinase–1 (sFlt-1) is secretory and functions as
a decoy receptor for VEGF ligands to compete with
VEGF receptors in target cells.8
Effector caspases are responsible for cleavage
of basic apoptotic substrates such as cell signaling
molecules, DNA repair enzymes, mRNA process­
ing components, cell skeleton and nuclear scaffold
proteins, and nuclease activator factors.9 It is rec­
ognized that caspase-3 is a key effector, and it is
common to both the mitochondria and the death
receptor pathway.10 Peluffo et al have shown that
apoptosis plays a key role in tissue remodeling
associated with regression of the rodent corpus
luteum and that caspase protein expression and/
or enzyme activity will increase during luteolysis
in the natural estrous cycle of the rat.11
Simvastatin is a modification of lovastatin,
serving as a rate-limiting enzyme in cholesterol
synthesis.12 Simvastatin is not well absorbed, and
less than 5% of an oral dose reaches the systemic
circulation. Simvastatin exerts anti-inflammatory
effects, induces angiogenesis, and promotes endo­
thelial cell growth.13
The aim of this study is to investigate the pro­
tective effect of simvastatin in the ovarian damage
caused by torsion and detorsion.
Materials and Methods
Experimental Design
All procedures performed in this experiment were
approved by the Ethics Committee for the Treat-
ment of Experimental Animals (Dicle University
Faculty of Medicine, Turkey). Healthy female Wis­
tar rats (250–280 g) were maintained under a con­
trolled temperature of 22±1°C and 12-hour light/
dark cycles, with free access to standard pellet
food (ad libitum). Estrus cycles were evaluated by
daily vaginal smear. Anesthesia was applied before
the surgical procedure because of high anxiety in
86 Analytical and Quantitative Cytopathology and Histopathology®
Toğrul and Deveci

3. the rats. Intramuscular ketamine hydrochloride (50
mg/kg Ketalar; Eczacibasi, Istanbul, Turkey) and
xylazine hydrochlo­
ride (10 mg/kg Rompun; Bayer
Türk I
·
laç Ltd, Istanbul, Turkey) were administered
to each rat for this purpose. In all of the groups, a
midline abdominal incision of 2.5 cm (laparotomy)
was performed under sterile conditions.
The groups were randomly divided as follows:
1. Control group (n=8). After anesthetizing all the
experimental animals, the ovaries were surgi­
cally opened and then closed. Blood and ova-
rian tissue samples of the animals were taken.
2. Ischemia group (n=8). The ovaries of the anes­
thetized animals were surgically opened, and the
left ovaries were sealed for ischemia.
3. Ischemia-reperfusion group (n=8). After 2 hours
of ischemia, blood flow was re-allowed for 2.5
hours of reperfusion. Then, the animals were
sacrificed with overdose anesthetic and ovarian
tissue samples were taken.
4. Ischemia-reperfusion+simvastatin group (n=8):
10 mg/kg simvastatin was given orally after the
reperfusion, and tissue specimens were taken
after 3 hours.
Malondialdehyde (MDA) and Glutathione Peroxidase
(GSH-Px) Assays
MDA levels and GSH-Px activities were deter-
mined in the ovary of each rat, and the average
values of each group were calculated. Each ovary
sample was prepared as a 10% homogenate (ac-
cording to weight) in 0.9% saline using a homog­
enizer on ice. Then, the homogenate was centri-
fuged at 2,000 rpm for 10 minutes, and the
supernatant was collected. MDA levels were de-
termined using the double heating method of
Draper and Hadley.14 The GSH-Px activity was
measured by the method of Paglia and Valentine.15
An enzymatic reaction was initiated by the addi-
tion of hydrogen peroxide (H2O2) to a tube that
contained reduced nicotinamide adenine dinu­
cleotide phosphate, reduced glutathione, sodium
azide, and glutathione reductase. The change in
absorbance at 340 nm was monitored by spec-
trophotometry. Data were expressed as U/g pro­
tein.
Histopathologic Analysis
The ovarium samples were fixed with neutral
buffered 10% formalin solution. After preserva­
tion, ovarian samples were directly dehydrated
in a graded series of ethanol and embedded into
paraffin wax. Five mm sections were cut with a
microtome (Rotatory Microtome, Leica, RM 2265,
Germany) and stained with hematoxylin and eosin
in order to be observed under light microscope.
Immunohistochemical Staining
Formaldehyde-fixed tissues were embedded in
paraffin wax for further immunohistochemical
examination. Sections were deparaffinized in xy-
lene and passed through descending alcohols.
Antigen retrieval process was performed in citrate
buffer solution (pH 6.0) for 5 minutes at 90°C in a
conventional microwave oven. They were allowed
to cool at room temperature for 30 minutes and
washed twice in distilled water for 5 minutes. En-
dogenous peroxidase activity was blocked in 0.1%
hydrogen peroxide for 20 minutes. Ultra V block
(Cat. No. 85-9043; Invitrogen, Carlsbad, California,
USA) was applied for 10 minutes prior to the
application of primary antibodies sFlt-1 antibody
(dilution rate, 1/100), cluster of differentiation
caspase-3 antibody (dilution rate, 1/100) over­
night. Secondary antibody (Cat. No. 85-9043; Invi­
trogen) was applied for 20 minutes. Slides were
then exposed to streptavidin-peroxidase for 20
minutes. Chromogen diaminobenzidine (DAB; In-
vitrogen) was used. Control slides were prepared
as mentioned above but omitting the primary
antibodies. After counterstaining with hematoxy­
lin and holding in distilled water for 10 minutes,
the slides were mounted with Entellan (Merck,
Germany).
Ovary sections were blindly analyzed by the
same histopathologist. Random areas from each
tissue were scored for each feature using a scale
of 0 to 3 (0=none, 1=mild, 2=moderate, 3=se-
vere, and 4=most severe).16 Histopathological fea-
tures for ovarian injury were follicular cell de-
generation (granulosa cells), vascular occlusion,
hemorrhage, and inflammation (neutrophil infil­
tration). Histopathological tissue injury scores
were determined as explained above. Tissue in-
jury scores of the groups are shown in Table I.
We compared follicle degeneration, vascular con­
gestion, edema, and inflammation between groups
(Figure 1).
Statistical Analysis
Statistical analysis of histopathological and bio­
chemical parameters was performed with SPSS
Volume 42, Number 3/June 2020 87
Simvastatin for Ovarian Torsion and Detorsion

4. (Version 22.0, SPSS Inc., Chicago, Illinois, USA).
Descriptive statistics were presented as median
(min-max) and mean±standard deviation values.
The significance of the difference among more
than two groups was evaluated by using the
Kruskal-Wallis test since data did not meet the
assumptions of the parametric test ANOVA. Post-
hoc tests with Bonferroni correction were used to
determine which groups differed with pairwise
comparison. A value of p<0.05 was considered as
statistically significant.
Results
We evaluated biochemical, histopathological, and
immunohistochemical parameters to determine
the efficacy of simvastatin on ischemia and reper­
fusion injury of rat ovaries. Parameter results are
statistically shown in Table I. When we compared
the groups in terms of MDA levels, a statistically
significant difference was found (p<0.05), espe­
cially in the ischemia and ischemia-reperfusion
groups: MDA values increased as compared to
the control group. In simvastatin administration,
88 Analytical and Quantitative Cytopathology and Histopathology®
Toğrul and Deveci
Table I Histopathological Parameters, Immunohistochemical Parameters, and Biochemical Parameters in All Studied Groups
Kruskal- Multiple
Wallis comparisons
Mean test for groups
Parameter Group N Mean±SD rank value (p<0.05)
Granular cell degeneration (1) Control 8 0.62±0.51 6.8 25,185 (2)(3)
p=0
(2) Ischemia 8 3.62±0.51 25.6 (1)(4)
(3) I/R 8 3.25±0.70 23.1 (1)(4)
(4) I/R+simvastatin 8 1.12±0.64 10.2 (2)(3)
Vascular dilation and congestion (1) Control 8 0.25±0.46 6.5 26,309 (2)(3)
p=0
(2) Ischemia 8 3.75±0.46 26.7 (1)(3)(4)
(3) I/R 8 3.00±0.75 22.2 (1)(2)(4)
(4) I/R+simvastatin 8 0.75±0.46 10.5 (2)(3)
Inflammation (1) Control 8 0.62±0.51 8.0 25,295 (2)(3)
p=0
(2) Ischemia 8 3.50±0.75 24.3 (1)(4)
(3) I/R 8 3.62±0.51 24.6 (1)(4)
(4) I/R+simvastatin 8 0.75±0.46 9.0 (2)(3)
Caspase-3 expression (1) Control 8 0.87±0.64 8.5 25,315 (2)(3)
p=0
(2) Ischemia 8 3.75±0.46 26.0 (1)(4)
(3) I/R 8 3.37±0.51 23.0 (1)(4)
(4) I/R+simvastatin 8 0.87±0.64 8.5 (2)(3)
sFlt-1 expression (1) Control 8 3.00±0.75 12.3 3,720
p=0.293
(2) Ischemia 8 3.37±0.51 16.6
(3) I/R 8 3.37±0.51 16.6
(4) I/R+simvastatin 8 3.62±0.51 20.3
GSH (1) Control 8 10.22±1.28 26.25 26,569 (2)(3)
p=0
(2) Ischemia 8 3.56±0.92 4.63 (1)(4)
(3) I/R 8 5.94±0.59 12.38 (1)(4)
(4) I/R+simvastatin 8 9.34±0.91 22.75 (2)(3)
MDA (1) Control 8 2.76±0.29 6.50 25,452 (2)(3)
p=0
(2) Ischemia 8 6.02±0.76 27.31 (1)(4)
(3) I/R 8 5.05±0.63 21.69 (1)(4)
(4) I/R+simvastatin 8 3.16±0.51 10.50 (2)(3)
GSH = glutathione, I/R = ischemia-reperfusion, MDA = malondialdehyde.

5. MDA decreased. GSH values decreased in the
ischemia and ischemia-reperfusion groups as com­
pared to the control group. In the simvastatin-
treated group, GSH value increased.
Discussion
Ovarian ischemia causes cell death due to in-
sufficient oxygen in the tissue. Ischemic tissues
need to recover blood supply for regeneration of
cells and disposal of toxic metabolites. However,
reperfusion of the ischemic tissue paradoxically
leads to much more serious damage to the tissue
than the damage caused by the ischemia.17 In
patients with adnexal torsion, an important fac-
tor for the prevention or reduction in ovarian
tissue damage is to keep the duration of ische-
mia brief. Currently, early conserving surgery
(detorsion/unwinding of the ovary) is considered
to be the most effective clinical approach to
treating ovarian torsion in girls and adolescents.16
Malondialdehyde (MDA) is the basic product of
polyunsaturated fatty acid peroxidation and is
quite a toxic molecule. Therefore, it is used to
determine in vivo and in vitro oxidative stress
levels.18
In a study by Cadirci et al that investigated the
efficacy of atorvastatin in the treatment of ovarian
ischemia-reperfusion injury,19 it was found that
MDA increased in ovarian tissue of the ischemia-
reperfusion group. In our study, while the MDA
level was high in both the ischemia and ischemia-
reperfusion groups, it decreased in the simvastat-
in group. Ischemia-reperfusion injury leads to the
production of excess amounts of highly reactive
molecules that cause damage to lipids, proteins,
and DNA as a result of a series of toxic events.20
GSH is one of the most important indicators of
antioxidant capacity which protects the tissues
against damage caused by oxidative stress. In the
study by Aksak Karamese et al21 it was reported
that GSH levels were significantly suppressed
when 3 hours of ischemia was followed by the
same period of reperfusion. In a study by Soylu
Karapinar et al,22 vascular congestion, edema,
Volume 42, Number 3/June 2020 89
Simvastatin for Ovarian Torsion and Detorsion
Figure 1 Comparison of histopathological, immunohistochemical, and biochemical parameters in all groups. MDA values were
increased in the ischemia and ischemia-reperfusion groups, close to the control group in the simvastatin-treated group as compared to
the control group. GSH values were decreased in the ischemia and ischemia-reperfusion groups and increased in the simvastatin-treated
group as compared to the control group. For the histopathological parameters, granular cell degeneration, vascular dilation, hemorrhage,
and inflammation levels were increased in the ischemia and ischemia-reperfusion groups as compared to the control group, but they
were similar to the control group in the simvastatin-treated group. Caspase-3 expression was increased by degeneration and apoptosis
in the ischemia and ischemia-reperfusion groups as compared to the control group. However, it was similar to the control group in the
simvastatin-treated group.

6. hemorrhage, and inflammatory cell infiltration
were observed in the ovarian tissue due to 3
hours of ischemia or 3 hours ischemia/3 hours
reperfusion.
Ozler et al16 showed that the number of follicles
decreased after torsion, reflecting the size of the
primitive follicle pool. They stated that a decrease
in the number of growing follicles was higher in
the detorsion group with dense cellular ischemia-
reperfusion injury. Our histochemical results are
shown in Figure 2. The control group showed a
normal appearance of the ovary with its follicles
and oocyte (Figure 2A). In the ischemia group,
oocyte cells and their associated structures were
mostly degenerated. Blood vessels were dilated and
congested with inflammation around them (Fig­
ure 2B). The ischemia-reperfusion group showed
histopathology similar to that of the ischemia
group (Figure 2C). The ischemia-reperfusion+
simvastatin–treated group seemed to be histolo­
90 Analytical and Quantitative Cytopathology and Histopathology®
Toğrul and Deveci
Figure 2 Hematoxylin and eosin staining of all groups. In the control group, oocytes of mature follicles were normal in shape with
oval nuclei surrounded by corona cells and granular cells. Theca externa was outside of follicles with dense connective fibers (A).
In the ischemia group, a degenerated oocyte with its degenerated corona and surrounding granular cells were observed. Atrophied
collagen fibrils, dilated blood vessels and intense congestion, and interfollicular inflammation and necrotic cells were also seen (B). In
the ischemia-reperfusion group, oocyte nuclei of the antral follicle were pyknotic. Surrounding cells were degenerated with apoptotic
changes. Stromal inflammation, dilated blood vessels, and congestion were also recorded (C). In the ischemia-reperfusion+simvastatin–
treated group, granular cells in the antral follicle were rich in chromatin. In fibrils around the follicle, stromal cells were regular. Slightly
dilated blood vessels and some apoptotic cells in the corpus luteum were observable (D).

7. gically normal, but some apoptotic figures were
still observable (Figure 2D).
In the reperfusion process that develops after
reactive oxygen derivatives after ischemia, acti­
vation of proapoptotic genes and proteases and
apoptosis in the caspase family occur. However,
it causes lipid peroxidation and cell damage by
disrupting the permeability of the cell membrane
structure.24 Many studies have shown that oxi­
dative stress and excessive inflammatory prod­
ucts, depending on their densities in ischemia-
reperfusion injuries, cause either reversible cell
damage or irreversible, lethal cell damage such as
apoptosis and necrosis.23
Sapmaz-Metin et al found that the number of
apoptotic cells increased significantly in the ova­
ries after ischemia-reperfusion.25 They detected
TUNEL-positive granulosa cells only in medium
or large ovarian follicles. They reported that
ischemia-reperfusion injury does not reduce the
ovarian germ cell pool but instead leads to oocyte
maturation problems due to loss of some internal
factors mediated by granulosa cell death. Our
caspase-3 immune staining results showed that
caspase-3 expression was predominantly negative
in follicular structures (Figure 3A). Degenerated
granular, luteal, and inflammatory cells expressed
caspase-3 (Figure 3B). The ischemia-reperfusion
group showed positive caspase-3 expression in oo-
cyte, granular, stromal cells, and theca cells in the
Volume 42, Number 3/June 2020 91
Simvastatin for Ovarian Torsion and Detorsion
Figure 3 Caspase-3 immunostaining of all groups. In the control group, caspase-3 expression in the oocyte and granular cells in the
preantral and antral follicles was negative, but it was positive in stromal cells adjacent to follicles (A). In the ischemia group, degenerated
granular cells in the antral follicle, luteal cells in the corpus luteum, and intense inflammatory cells in the stromal region showed positive
expression of caspase-3 (B). In the ischemia-reperfusion group, caspase-3 expression was positive in oocyte, granular, stromal cells, and
theca cells in the mature antral follicle (C). Caspase-3 expression was negative in preantral follicular cells and granular cells around the
antral follicle in the ischemia-reperfusion+simvastatin group, whereas it was positive in some stromal cells and corpus luteum cells (D).

8. mature antral follicle (Figure 3C). In the ischemia-
reperfusion+simvastatin group, caspase-3 expres­
sion was negative in follicular structures but pos­
itive in some stromal cells and corpus luteum cells
(Figure 3D).
Angiogenesis is one of the major features of the
early corpus luteum. VEGF is the most important
factor in the regulation of both normal and ab-
normal angiogenesis.7 VEGF-A, a potent stimula­
tor of endothelial cell proliferation and migration
and also a promoter of vascular permeability, is
the major angiogenic factor that controls follicu-
lar angiogenesis.26 An increase in VEGF-A expres­
sion and neovascularization by atorvastatin was
previously reported by Matsumura et al.27 By in-
creasing neovascularization, statins maintain mi-
crovascular circulation and improve tissue per­
fusion.28 sFlt-1 is secreted from endothelial cells
into their immediate extracellular space as well as
into the general circulation and reduces the bio-
availability of VEGF by binding and sequester-
ing this growth factor.29 Our sFlt-1 immunostain­
ing results are shown in Figure 4. In the control
group, sFlt-1 expression was positive in vascular-
associated structures (Figure 4A). sFlt-1 was posi-
tively expressed in degenerated follicular cells,
92 Analytical and Quantitative Cytopathology and Histopathology®
Toğrul and Deveci
Figure 4 sFlt-1 immunostaining of all groups. In the control group, sFlt-1 expression was positive in the vascular endothelial cells
between the preantral and antral follicles and in some stromal macrophage cells (A). In the ischemia group, the expression of sFlt-1
was positive in degenerated preantral and antral follicle cells, vascular endothelial cells, and inflammatory cells (B). In the ischemia-
reperfusion group, increased sFlt-1 expression was observed in luteal cells of the corpus luteum, vascular endothelial, and inflammatory
cells (C). In the ischemia-reperfusion+simvastatin group, follicular and corpus luteum cells showed decreased sFlt-1 expression, whereas
sFlt-1 expression was positive in vascular endothelial cells (D).

9. vascular cells, and inflammatory cells in the ische­
mia group (Figure 4B). The ischemia-reperfusion
group showed increased sFlt-1 expression in cor-
pus luteum, vascular endothelial inflammatory
cells (Figure 4C). In the ischemia-reperfusion+sim­
vastatin group, sFlt-1 expression was decreased in
follicular structures (Figure 4D).
Depending on the duration of torsion and de-
torsion, apoptosis may be increased due to pro­
apoptotic activation, and simvastatin adminis-
tration could prevent cell damage by affecting
proapoptosis activation. Simvastatin administra­
tion was thought to induce the regulation of
angiogenesis.
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