Effect of in-utero diethylstilboestrol exposure on human oocyte quality and fertilization in a programme of in-vitro fertilization

In vivo and in vitro environmental effects on mammalian oocyte quality

The oocyte is at the center of the equation that results in female fertility. Many factors influence oocyte quality, including external factors such as maternal nutrition, stress, and environmental exposures, as well as ovarian factors such as steroids, intercellular communication, antral follicle count, and follicular fluid composition. These influences are interconnected; changes in the external environment of the female translate into ovarian changes that affect the oocyte. The lengthy period during which the oocyte remains arrested in the ovary provides ample time and opportunity for environmental factors to take their toll. An appropriate environment for growth and maturation of the oocyte, in vivo and in vitro, is critical to ensure optimal oocyte quality, which determines the success of fertilization and preimplantation embryo development, and has long-term implications for implantation, fetal growth, and offspring health.

Endometrial receptivity is preserved in Diethylstilbestrol-associated and other Müllerian anomalies: evidence from tubal embryo transfer

PURPOSE

To report implantation and pregnancy rates following TET in women with anomalous uteri, and to compare these with previously reported rates following trans-cervical ET.

MATERIALS AND METHODS

Between 1995 and 2003, 12 TET procedures were performed in seven women with Müllerian anomalies. Tubal ET was performed via laparoscopy 48 h after standard IVF in 3 cycles in two patients, whereas in 9 cycles in five patients, TET was performed 24 h or 48 h following oocyte donation.

RESULTS

Of the seven patients, 5 (71%) had a history of 15 failed cycles with trans-cervical ET. The 12 TET procedures resulted in eleven clinical pregnancies (92%; 95% CI: 63, 99%). There were seven deliveries/ongoing pregnancies (58%; 95% CI: 27%, 85%).

CONCLUSIONS

We observed high implantation and ongoing pregnancy rates in women with Müllerian anomalies, suggesting that 1) endometrial receptivity in anomalous uteri is preserved, and 2) transfer efficiency is reduced but may be restored with the use of TET.

Utérus DES. Polémiques sur l'hystéroplastie d'agrandissement. Arguments contre

Uterine malformations in DES-exposed women are not the only aetiologies for infertility, miscarriages, and other problems in their reproductive life. A global screening of fertility factors of the couple may, for instance, show in them vascular uterine abnormalities which reduce their reproductive potential. Furthermore, these abnormalities are not always predictive of losses of pregnancy, and many exposed women with patent uterine abnormalities can carry a pregnancy to term. Metroplasty for uterine enlargement is a surgical procedure suggested for restoring the size and shape of the uterine cavity. There are no comparative studies for assessing efficacy and safety of metroplasty. Therefore, metroplasty should not be performed routinely, but should only be considered after the couple has undergone a full fertility workup, and the best possible level of fertility has been achieved.

[Uterine malformations and reproduction]

The frequency of uterine malformations impacting on reproduction seems not easy to determine. Their diagnosis needs specific explorations (hysterosalpingography, hysteroscopy and laparoscopy). Spontaneous fertility may be impaired in relation with uterine abnormalities. All these abnormalities could have repercussions on the conceptus' evolution like abortion, preterm delivery, vascular pathologies and intrauterine growth restriction. Ovarian function does not seem to be altered even though implantation rate could be reduced. Surgery, especially endoscopy, allows a precise diagnosis, a prognostic evaluation and an adequate treatment improving conception rates and pregnancy outcome. Mainly hysteroscopic septum section and expansion metroplasty were regularly described.

Les sections de cloisons et les plasties d'agrandissement ont-elles réellement un impact obstétrical ?

The aim of metroplasties is to restore a normal uterine anatomy to improve obstetrical outcomes in some uterine malformations. The hysteroscopic septoplasty cures the septate uterus. It is an effective procedure in the case of recurrent abortion losses. It probably improves the rate of live birth in women without obstetrical antecedent. For some authors, it could be considered at the time of the diagnosis, because of the simplicity of the gesture and the low complication rate. The enlarging hysteroscopic metroplasty has certainly a positive impact on the obstetrical outcome in patients presenting a uterine hypotrophy or dysmorphy, in particular in women exposed in utero to DES. However, the proofs are poor to propose this procedure as first-line treatment, apart from specific cases such as old null gravid patient or before inclusion in an Assisted Reproductive Techniques (ART) program.

Female genital anomalies affecting reproduction

OBJECTIVE

A multitude of female congenital anomalies are uncommon. However, their impact on reproduction can be profound. The aim of this review is to remind the practicing physician of the clinically relevant embryology and summarize the studies that look at the impact of such various anomalies on a woman's fecundity. We review particular surgical therapies that possibly may improve fertility in such women.

DESIGN

Review and critique of available studies in which particular surgical therapies were done and whether they truly improved fertility in these women with congenital reproductive anomalies.

RESULTS

Clear evidence demonstrates that uterine septum resection is effective in women with demonstrated recurrent pregnancy losses. Arcuate uterus has little impact on reproduction. Other studies fail to definitively show that surgical correction will improve pregnancy retention or fertility except for specifically indicated clinical scenarios.

CONCLUSIONS

The practicing reproductive specialist should have working knowledge of evidence-based therapeutic options for women with reproductive congenital anomalies. A summary chart has been devised to clearly associate embryologic structures with normal adult derivative as well as anomalous structures.

Effects of Mullerian anomalies on in vitro fertilization outcome

PURPOSE

To assess the effect of Mullerian anomalies on pregnancy rates in women undergoing in vitro fertilization (IVF).

METHODS

The records of 37 patients with and 819 patients without Mullerian anomalies undergoing a first cycle of IVF between December 1995 and July 1998 were included in this retrospective study. Outcome variables included maximal estradiol level, number of days of stimulation, number of follicles, number of oocytes, fertilization rate, and ongoing/livebirth pregnancy rate.

RESULTS

Patients with Mullerian anomalies had a significantly lower ongoing pregnancy rate (8.3%) than did controls (24.8%). No patients with diethylstilbestrol (DES)-related anomalies had an ongoing pregnancy.

CONCLUSIONS

Among women with Mullerian anomalies, those with DES exposure in utero demonstrated the poorest outcome.