Structure and function of the fallopian tubes following exposure to diethylstilbestrol (DES) during gestation

Developmental exposure to phytoestrogens found in soy: New findings and clinical implications

Exposure to naturally derived estrogen receptor activators, such as the phytoestrogen genistein, can occur at physiologically relevant concentrations in the human diet. Soy-based infant formulas are of particular concern because infants consuming these products have serum genistein levels almost 20 times greater than those seen in vegetarian adults. Comparable exposures in animal studies have adverse physiologic effects. The timing of exposure is particularly concerning because infants undergo a steroid hormone-sensitive period termed "minipuberty" during which estrogenic chemical exposure may alter normal reproductive tissue patterning and function. The delay between genistein exposure and reproductive outcomes poses a unique challenge to collecting epidemiological data. In 2010, the U.S. National Toxicology Program monograph on the safety of the use of soy formula stated that the use of soy-based infant formula posed minimal concern and emphasized a lack of data from human subjects. Since then, several new human and animal studies have advanced our epidemiological and mechanistic understanding of the risks and benefits of phytoestrogen exposure. Here we aim to identify clinically relevant findings regarding phytoestrogen exposure and female reproductive outcomes from the past 10 years, with a focus on the phytoestrogen genistein, and explore the implications of these findings for soy infant formula recommendations. Research presented in this review will inform clinical practice and dietary recommendations for infants based on evidence from both clinical epidemiology and basic research advances in endocrinology and developmental biology from mechanistic in vitro and animal studies.

Homeobox genes for embryo implantation: From mouse to human

The proper development of uterus to a state of receptivity and the attainment of implantation competency for blastocyst are 2 indispensable aspects for implantation, which is considered to be a critical event for successful pregnancy. Like many developmental processes, a large number of transcription factors, such as homeobox genes, have been shown to orchestrate this complicated but highly organized physiological process during implantation. In this review, we focus on progress in studies of the role of homeobox genes, especially the Hox and Msx gene families, during implantation, together with subsequent development of post-implantation uterus and related reproductive defects in both mouse models and humans, that have led to better understanding of how implantation is precisely regulated and provide new insights into infertility.

Molecular mechanisms of induction of persistent changes by estrogenic chemicals on female reproductive tracts and external genitalia

The effects of environmental endocrine-disrupting chemicals (EDCs) are a great and growing concern for human and animal development and life. The reproductive organs are considered as a primary target of EDCs, yet the effects on reproductive organs can extend to other body systems. Perinatal diethylstilbestrol (DES)-exposed mice exhibit various reproductive organ abnormalities. The perinatal DES-exposure model has allowed insight into our understanding of the mechanisms of persistent reproductive organ abnormalities elicited by exposure to estrogens and/or estrogenic EDCs. The persistent changes in the vagina of neonatally DES-exposed mice result from sustained expression of growth factors by ligand-independent transcriptional activation of the estrogen receptor. Developmental regulatory genes, such as Wnt and Hox genes, are also targets of DES during fetal stages and altered gene expression can induce malformations of the reproductive organs. In this review, we focus on the development of female reproductive tracts and external genitalia, and discuss the recent progress in understanding the disruptive effects of estrogens and EDCs on these organs.

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.

Endocrine regulation of HOX genes

Hox genes have a well-characterized role in embryonic development, where they determine identity along the anteroposterior body axis. Hox genes are expressed not only during embryogenesis but also in the adult, where they are necessary for functional differentiation. Despite the known function of these genes as transcription factors, few regulatory mechanisms that drive Hox expression are known. Recently, several hormones and their cognate receptors have been shown to regulate Hox gene expression and thereby mediate development in the embryo as well as functional differentiation in the adult organism. Estradiol, progesterone, testosterone, retinoic acid, and vitamin D have been shown to regulate Hox gene expression. In the embryo, the endocrine system directs axial Hox gene expression; aberrant Hox gene expression due to exposure to endocrine disruptors contributes to the teratogenicity of these compounds. In the adult, endocrine regulation of Hox genes is necessary to enable such diverse functions as hematopoiesis and reproduction; endocrinopathies can result in dysregulated HOX gene expression affecting physiology. By regulating HOX genes, hormonal signals utilize a conserved mechanism that allows generation of structural and functional diversity in both developing and adult tissues. This review discusses endocrine Hox regulation and its impact on physiology and human pathology.

Hysterosalpingography

OBJECTIVE

To demonstrate the value of the hysterosalpingogram in the evaluation of infertility.

CONCLUSION(S)

Hysterosalpingography, which should be done in the follicular phase of the cycle, evaluates the contour of the uterine cavity, cervical canal, and tubal lumina. Other than being diagnostic, it can prove to be therapeutic. The instrument used to introduce the radio-opaque medium should be chosen to give the least discomfort and to cause no leakage of dye from the cervix. Water-soluble medium is usually used rather than an oil-based medium. Fluoroscopy with image intensification gives the best results. Insufficient dye injection will give an incomplete study. Too much dye injection, especially under pressure, might cause extravasation of the dye into the vascular system or conceal the fimbrial ends of the tubes.

Résultats obstétricaux de 454 femmes exposées au diéthylstilboestrol pendant leur vie fœtale : analyse cas-témoins

OBJECTIVE

To analyze the predictive effect on obstetrical outcome in women with prenatal exposure to diethylstilbestrol (DES) of previous obstetrical history or the specific risk of DES exposure.

PATIENTS AND METHODS

We included all in utero DES-exposed women (454 women) followed and delivered at one maternity unit in Paris and compared them with two control women matched for age, parity, number of late fetal losses, number of previous preterm births, number of singleton or twin fetuses, and follow-up, who were managed by the same team or referred for pregnancy complication.

RESULTS

DES women had a higher rate of preterm birth (19.2%) than matched controls (10.5%), even when considering women with a previous preterm birth or twin pregnancy. The rate of fetal or neonatal deaths were lower in DES-exposed women than in controls. DES women showed a higher rate of severe post partum bleeding (2.8%) than matched controls (1.5%) or the global population of women delivered in this maternity unit.

CONCLUSION

A history of prenatal exposure to DES is a major predictor of preterm birth for primiparous women and for those with an adverse obstetrical history.

Amélioration du pronostic obstétrical des femmes porteuses d’un utérus distilbène par une prise en charge adaptée

OBJECTIVE

To define the interest of a specific care management of pregnancies in patients exposed in utero to diethylstilbestrol, with the intention of reducing the number of spontaneous miscarriage and prematurity.

PATIENTS AND METHODS

One hundred and three pregnancies in 49 patients exposed in utero to diethylstilbestrol were followed during a 4-year study, while establishing a specific care management of pregnancies in those women.

RESULTS

Spontaneous miscarriage rate was 18.5%, among which 16.5% before 15 weeks of pregnancy and 2% after 15 weeks of pregnancy. Premature birth rate was 41.9%, among which 10.8% of great premature birth (before 32 weeks of pregnancy), 13.5% of moderate premature birth (between 32 and 36 weeks of pregnancy), and 17.6% of minor prematurity (after 36 weeks of pregnancy). The patients' average delivery term was 36 +/-3.6 weeks.

DISCUSSION AND CONCLUSION

As compared with the literature data, our miscarriage and prematurity rates are found to be lower. Our specific care management seems thus to be effective.

Müllerian Duct Anomalies: Imaging and Clinical Issues

While estimates of the frequency of müllerian duct anomalies vary widely owing to different patient populations, nonstandardized classification systems, and differences in diagnostic data acquisition, these anomalies are clinically important, particularly in women who present with infertility. An understanding of the differences between these uterovaginal anomalies, as outlined in the most widely accepted classification system-that published by the American Fertility Society (AFS) in 1988-is imperative given the respective clinical manifestations, different treatment regimens, and prognosis for fetal salvage. Although the AFS classification system serves as a framework for description of anomalies, communication among physicians, and comparison of therapeutic modalities, there often is confusion about appropriate reporting of certain anomalies, particularly those with features of more than one class. Many of the anomalies are initially diagnosed at hysterosalpingography and ultrasonography; however, further imaging is often required for definitive diagnosis and elaboration of secondary findings. At this time, magnetic resonance imaging is the study of choice because of its high accuracy and detailed elaboration of uterovaginal anatomy. Laparoscopy and hysteroscopy are reserved for women in whom interventional therapy is likely to be undertaken.

In utero effects of chemicals on reproductive tissues in females

Chemicals found in the environment as industrial byproducts or pollutants as well as those that are prescribed or part of our daily lives can have multiple effects on the human body. The manner in which we are exposed, and the levels we are exposed to are significant contributing factors. Adults have the bodily defense mechanisms in place to combat exposures to adverse toxicants and general pollution at a variety of levels. However, developing organisms may not have adequate defense mechanisms, and toxicants can have a significant effect on their health and development. In this review, we take particular note of the toxicities of chemicals on the developing female reproductive system as a result of in utero exposure. Environmental and prescribed chemicals such as 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), polychlorinated biphenyls (PCBs), polycyclic aromatic hydrocarbons (PAHs), diethylstilbestrol, and genistein, as well as others, will be reviewed for their in utero toxicity in the neuroendocrine system, the ovary, oviduct, placenta, uterus, vagina, cervix, and mammary gland.

Magnetic resonance imaging of mullerian duct anomalies of the uterus

Congenital uterine anomalies (mullerian duct anomalies) comprise a spectrum of developmental malformations associated with varying degrees of adverse reproductive outcomes. Although traditionally diagnosed by hysterosalpingography or ultrasound, further elaboration of the findings frequently was performed with laparoscopy/laparotomy and hysteroscopy. The need for diagnostic surgical intervention has largely been eclipsed with the advent of magnetic resonance imaging, which has become the imaging modality of choice for characterization of congenital mullerian anomalies.

Intrauterine exposure to diethylstilbestrol: long-term effects in humans

DES is the most carefully scrutinized EDC and its history provides valuable insights into the current evaluation of less well-studied EDCs. This review summarizes the health effects of prenatal exposure to diethylstilbestrol (DES) and emphasizes the role of DES as the first endocrine disrupting chemical (EDC). Vaginal clear cell adenocarcinoma (CCAC), the most severe consequence of prenatal exposure to DES, affected only 0.1% of exposed females, while the far more prevalent teratogenic and reproductive effects of DES were only discovered when DES daughter were screened for CCAC. Initial studies, conducted before most DES daughters had tried to conceive, examined vaginal cancer and vaginal, cervical and uterine abnormalities. Subsequently, several controlled studies demonstrated the increased risk of adverse reproductive outcomes in DES daughters. While most DES daughters can eventually experience a live birth, this is less likely in women with genital tract abnormalities, in whom there is a two-thirds chance that each pregnancy will be unsuccessful. In DES sons, who have been far less studied, results suggest male reproductive toxicity, but are less consistent. The importance of dose and gestational age at initial exposure are discussed, and the implications of DES findings for the evaluation of risks from current EDCs emphasized.

In utero diethylstilbestrol (DES) exposure alters Hox gene expression in the developing müllerian system

Diethylstilbestrol (DES) was widely used to treat pregnant women through 1971. The reproductive tracts of their female offspring exposed to DES in utero are characterized by anatomic abnormalities. Here we show that DES administered to mice in utero produces changes in the expression pattern of several Hox genes that are involved in patterning of the reproductive tract. DES produces posterior shifts in Hox gene expression and homeotic anterior transformations of the reproductive tract. In human uterine or cervical cell cultures, DES induces HOXA9 or HOXA10 gene expression, respectively, to levels approximately twofold that induced by estradiol. The DES-induced expression is not inhibited by cyclohexamide. Estrogens are novel morphogens that directly regulate the expression pattern of posterior Hox genes in a manner analogous to retinoic acid regulation of anterior Hox genes. Alterations in HOX gene expression are a molecular mechanism by which DES affects reproductive tract development. Changes in Hox gene expression are a potential marker for the effects of in utero drug use that may become apparent only at late stages of development.

Effect of diethylstilbestrol on reproductive function

OBJECTIVE

To review the effects of in utero exposure to diethylstilbestrol (DES) on müllerian development and subsequent reproductive function.

DESIGN

The literature on DES and reproductive function was reviewed and summary data are presented. The studies were identified through the computerized MEDLINE database and a manual search of relevant bibliographies.

RESULT(S)

In utero exposure to DES resulted in reduced fertility and increased rates of ectopic pregnancy, spontaneous abortion, and preterm delivery.

CONCLUSION(S)

An understanding of the reproductive performance of women who were exposed to DES in utero is useful for counseling these patients regarding their risks and treatment options.

Abdominal B (AbdB) Hoxa genes: regulation in adult uterus by estrogen and progesterone and repression in müllerian duct by the synthetic estrogen diethylstilbestrol (DES)

Mice deficient for the Abdominal B (AbdB) Hox gene Hoxa-10 exhibit reduced fertility due to defects in implantation. During the peri-implantation period Hoxa-10 is sequentially expressed in the uterine epithelium and stroma. These observations, combined with the stringent regulation of uterine implantation by ovarian steroids, prompted us to test whether estrogen and progesterone directly regulate the expression of Hoxa-10 and other AbdB Hoxa genes. Here we show that Hoxa-10 expression in the adult uterus is strongly activated by progesterone. This activation is blocked by the progesterone receptor antagonist RU486 and is independent of new protein synthesis. In addition, Hoxa-10 expression is repressed by estrogen in a protein synthesis-independent manner. Analysis of adjacent AbdB Hoxa genes reveals that Hoxa-9 and a-11 are also activated in a colinear fashion by progesterone but differentially regulated by estrogen. These results suggest that the regulation of AbdB Hox gene expression in the adult uterus by ovarian steroids is a property related to position within the cluster, mediated by the direct action of estrogen and progesterone receptors upon these genes. We next examined whether the embryonic expression of Hoxa10 is regulable by hormonal factors. Previous work has demonstrated that perinatal administration of the synthetic estrogen diethylstilbestrol (DES) to mice and humans produces uterine, cervical, and oviductal malformations. Certain of these phenotypes resemble those in Hoxa-10 knockout mice, suggesting that Hoxa-10 gene expression might be repressed by DES during reproductive tract morphogenesis. Exposure of the developing female reproductive tract to DES, either in vivo or in organ culture, represses the expression of Hoxa-10 in the Müllerian duct. Thus, these data not only establish a direct link between ovarian steroids and AbdB Hoxa gene expression in the adult uterus, but also provide a potential mechanism for the teratogenic effects of DES on the developing reproductive tract.

Prenatal exposure to diethylstilbestrol and the mother-daughter relationship

The psychological consequences resulting from the exposure to diethylstilbestrol (DES), a non-steroidal oestrogen, on the mother-daughter relationship are studied using semi-directive interviews with 43 daughters and 7 mothers treated with DES during their pregnancies. These women referred to gynaecological consultation for DES-related problems. The daughters, exposed to DES during their foetal life, learned about DES after a pregnancy mishap (35% of the cases), or by accident (65% of the cases). All of them were shocked when the existence of DES and its side effects were revealed to them. Consequences on the mother-daughter relationship were absent in 60% of the cases, favourable in 20%, and negative in 20%. Five percent of the women showed hostility towards the medical practice, but 65% were not suspicious of the drugs administered to them during their pregnancies. For 64% of them, administration of DES to their mother had been kept secret. In 7 out of 50 cases, parents alone came for medical assistance in order to manage the secret. Exposure to DES may reveal pre-existing difficulties not only between the mother and the daughter, but sometimes beyond from generation to generation.

Gamete intrafallopian transfer: ethical considerations, historical development of the procedure, and comparison with other advanced reproductive technologies

OBJECTIVE

To report on ethical considerations regarding GIFT as well as the developmental history of the procedure and to review the literature and compare it with other advanced reproductive technologies (ARTs).

DESIGN

Indications, patient screening, recent evaluations, methods of ovarian hyperstimulation and oocyte retrieval-assessment, gamete transfer and pregnancy outcome are discussed in this review. A comparison of GIFT with other ARTs is also attempted.

MAIN OUTCOME MEASURES

Gamete intrafallopian transfer pregnancy determination and outcome.

CONCLUSIONS

Gamete intrafallopian transfer is an ethically acceptable procedure by different religious groups. In a selected group of patients, GIFT is an acceptable and, in some occasions, a preferable procedure to other ARTs.

Effects of prenatal exposure to diethylstilbestrol (DES) on hemispheric laterality and spatial ability in human males

Ten males exposed to diethylstilbestrol (DES), a nonsteroidal synthetic estrogen, during gestation were compared to their matched, unexposed brothers on measures of brain hemispheric specialization for processing nonlinguistic spatial information and cognitive abilities. DES exposure was associated with reduced hemispheric laterality and lowered spatial ability. These data provide direct evidence of a relationship between brain laterality, spatial cognitive ability, and prenatal exposure to hormones in human males. Further, the implications of these findings for understanding sexual differentiation of the human brain are discussed.

Histologic, morphometric, and immunocytochemical analysis of myometrial development in rats and mice: II. Effects of DES on development

The effects of diethylstilbestrol (DES) treatment on myometrial development from the prenatal to adult period were examined in rats and mice by histologic and immunocytochemical methods using anti-actin, -vimentin, and -laminin to assess cytodifferentiation of smooth muscle and fibroblastic cells, and by morphometric procedures to assess quantitatively the effect of DES on the expression of cellular orientation in the emerging inner circular myometrial layer. Neonatal rats and mice were treated with DES from day 0 (day of birth) to day 2 with dosages known to perturb myometrial development. Neonatal treatment with DES increased the degree of circular orientation within the uterine mesenchyme, an effect detectable following as little as 24 hr of DES treatment. This effect on spatial organization of the mesenchyme was followed by an increase in the thickness of the actin-positive middle layer (prospective circular myometrium) of uterine mesenchyme during days 3-15; from day 15 onward, however, the circular myometrial layer began to fragment into irregular bundles of smooth muscle, and the longitudinal myometrial layer became thinner and more irregularly organized than controls. Vimentin localization in rats treated with DES neonatally was more intense than in controls within the circularly orientated uterine mesenchyme at 5 days. By 60 days the circular and longitudinal myometrial layers of DES-treated animals showed strands and bundles of vimentin-positive cells, which were not present in controls. Both rats and mice show comparable effects of DES treatment.

Teratogenic effects of clomiphene, tamoxifen, and diethylstilbestrol on the developing human female genital tract

The potential estrogenicity and teratogenicity of triphenylethylene antiestrogens were examined in 54 genital tracts isolated from 4- to 19-week-old human female fetuses and grown for 1 to 2 months in untreated athymic nude mice or host mice treated by subcutaneous pellet with the antiestrogens clomiphene and tamoxifen or the synthetic estrogen diethylstilbestrol (DES). In specimens grown to a gestational age equivalent of 15 weeks or less, the vagina and urogenital sinus were lined by an immature squamous epithelium, which were similar in both drug-treated and untreated specimens. Proliferation and maturation of the squamous vaginal epithelium were observed in specimens treated with clomiphene, tamoxifen, or DES only when grown to a gestational age equivalent of 16 weeks or more. Formation of endometrial and cervical glands proceeded in 87 per cent (13 of 15) of control specimens grown to a gestational age equivalent of 13 weeks or more in untreated hosts. By contrast, age-matched drug-treated specimens contained glands in only 44 per cent (12 of 27) of specimens. In the developing uterine corpus of untreated controls, the uterine mesenchyme segregated into inner (endometrial stroma) and outer (myometrial) layers; whereas in drug-treated specimens, condensation and segregation of the mesenchyme were greatly impaired. The fallopian tube was also affected by clomiphene and tamoxifen (and to a lesser extent by DES) in that its epithelium was hyperplastic and disorganized. The complex mucosal plications characteristic of the fallopian tube were also distorted in drug-treated specimens. These results emphasize the heretofore unrecognized estrogenicity and potential teratogenicity of triphenylethylene antiestrogens on the developing human genital tract and emphasize the need for caution to prevent inadvertent exposure of the developing fetus to these compounds.

Long-term evaluation of the diethylstilbestrol (DES) syndrome in adult female rhesus monkeys (Macaca mulatta)

This study was designed to examine the transplacental effects of diethylstilbestrol (DES) in rhesus monkeys (Macaca mulatta). Nineteen pregnant females received an approximate human therapeutic dose of 1 mg/day DES beginning on gestational day 21 (Group I), day 100 (Group II), or day 130 (Group III) until term. Colposcopic examination and vaginal biopsies were performed in eight female offspring at 6- and 12-month intervals beginning at 3.5 years of age until death between 5 and 12 years of age. Gross and histological evidence of vaginal adenosis was observed in five of eight (62.5%) females. Adenosis, which occurred in all treatment groups, did not develop into neoplasia; rather, it underwent metaplasia and reversion to squamous epithelium, a frequent observation in human DES cases. The vaginal ridging and/or cervical hooding characteristic of the human syndrome was observed in all exposed females. Although menstrual cyclicity was not impaired, there appeared to be a lower pregnancy rate in treated animals compared to age-matched controls. This long-term evaluation of reproductive morphology and function in the rhesus monkey has provided a useful model for studying the history of benign vaginocervical abnormalities induced by prenatal DES treatment.

Histology of the adult mouse oviduct and endometrium following a single prenatal exposure to diethylstilbestrol

Light microscopy was used to examine the oviduct and endometrium of offspring from mice administered DES (10 micrograms/kg in 0.1 cc of corn oil, subcutaneously) or corn oil alone on Day 15 of gestation. Offspring were sacrificed at 5, 7 and 9 months of age. Oviduct changes in DES exposed offspring included numerous abnormal secretory cells which lined the mucosal folds of the isthmus. These cells contained a distinct granular cytoplasm which was eosinophilic and a nucleus displaced towards the apical surface. In addition both the ampulla and isthmus had mucosal folds which extended to the serosal surface and an accumulation of subepithelial fibrinoid material. Endometrial changes included squamous metaplasia of both the surface and glandular epithelial layer as well as extensive cystic glandular hyperplasia. In addition the endometrial connective tissue stroma exhibited fibrinoid accumulation. These changes may reflect an altered endocrine environment resulting from ovarian abnormalities during adulthood.

Abnormalities in the reproductive system of aged mice after neonatal estradiol exposure

Female mice of the BALB/c strain were treated neonatally with 17 beta-estradiol (E2) or sesame oil and sacrificed at 20 months of age. Neonatal treatment of mice with E2 resulted in the development of vaginal lesions, including adenosis, adenocarcinoma and squamous-cell carcinoma. While the neonatal treatment also induced squamous metaplasia in the uterine epithelium, development of uterine adenomatous hyperplasia was markedly inhibited in the estrogen-treated mice when compared to the oil-treated controls. However, neonatal exposure to E2 resulted in a high incidence of ovarian tumors and epithelial hyperplasia of the oviduct. Thus, the effects of neonatal treatment with estrogen appeared to interact with the usual effects of aging, modifying the development of pathological abnormalities in the various reproductive organs of mice.

Progressive proliferative changes in the oviduct of mice following developmental exposure to diethylstilbestrol

Structural malformation of the oviduct has been reported in experimental animal models and women following prenatal exposure to diethylstilbestrol (DES). To study histological changes in the oviduct in the absence of gross structural malformation, neonatal CD-1 mice were treated with DES (2 micrograms/pup/day) on days 1-5 of age. Focal epithelial hyperplasia was present at 1 month of age in 16 out of 18 (89%) of the DES-treated mice. At 4 months of age, general epithelial hyperplasia with multiple gland-like structures into and through the muscle wall of the oviduct was observed in 90% of the treated mice; by 12 months of age, epithelial hyperplasia and pseudogland formation were seen in 100% of the DES-exposed animals. Epithelial hyperplasia and gland formation were not observed in control mice. The alteration induced by DES in the differentiation and proliferation of mouse oviductal epithelium suggests that the oviduct is a target for DES toxic effects. In addition, there was a progression of the epithelial changes with age. The histological changes described in this study may be partially responsible for the decreased fertility previously reported in this mouse model. Similar changes in the oviduct of DES-exposed women remain to be determined.

The role of the estrogen receptor in diethylstilbestrol toxicity

The site and specificity of the tissue response to a toxicant are of central importance; it is in this area of diethylstilbestrol (DES) toxicity that the estrogen receptor would appear to play its primary role. Compilation of the various sites of DES toxicity in humans and experimental animals indicates that lesions appear predominantly in estrogen responsive target tissues suggesting that the presence of the estrogen receptor in such target tissues may help govern the tissue specificity of the toxic insult. DES and many of its oxidative metabolites interact with high affinity with the estrogen receptor. Such an interaction may be responsible for localizing DES to target tissues. Autoradiographic and biochemical studies have supported the localization of radiolabeled DES in susceptible tissues. The intracellular mechanism of receptor binding of DES and certain metabolites could then result in mobilization of these compounds to the nucleus. Experimental evidence has shown that DES and a number of its metabolites are able to translocate receptor to the nucleus of uterine cells. Such an action by the receptor results in an increased probability of potential chemical interactions with the genome. The actual induction of a chemical lesion in the target cell may, at this point, proceed by non-receptor mediated mechanisms. For example, studies using in vitro cell culture systems which contain no estrogen receptors have shown that DES can induce neoplastic cell transformation, mutagenesis, irreversible binding to DNA and protein and unscheduled DNA synthesis. These results raise the possibility that a part of DES toxicity may follow pharmacologic principles established for chemical carcinogens. Following induction of the molecular lesion, the role of the receptor continues in this process by mediating increased protein synthesis and mitogenesis in responsive target tissues which ultimately permits a more extensive expression of the toxic effects. It has been demonstrated that DES is a potent mitogen in vivo in both uterine and pituitary tissues, subsequently, the lesion will perpetuate itself through this receptor mediated biological response. This is particularly important since a number of DES induced reproductive tract tumors are expressed only after additional estrogen exposure. While other tumors have been shown to be estrogen sensitive and will regress without continued estrogen stimulation. Therefore, it should be considered that the presence of the estrogen receptor and the estrogen receptor mediated biological responsiveness of a particular tissue are most important in explaining the specificity of DES toxicity.

Experience with diethylstilbestrol-exposed infertile women in a program of in vitro fertilization

Twenty infertile women with a history of diethylstilbestrol exposure in utero were seen in Norfolk for the purpose of in vitro fertilization. Seventeen patients had undergone 25 stimulated cycles with harvest of oocytes by laparoscopy. The serum estradiol response to stimulation in these patients and the number and quality of oocytes retrieved did not differ significantly from those of patients with infertility due to blocked fallopian tubes. There were four pregnancies in 17 patients after 21 cycles of embryo transfers, for a pregnancy rate of 23.5% per patient, or 19% per embryo transfer. Two of the pregnant patients have had a term delivery, one has had a preclinical abortion, and one has a single intrauterine gestation in progress.

Hysterosalpingography

A brief review of the technique of hysterosalpingography is provided. It remains an important diagnostic study in searching for causes of infertility. HSG is a safe, simple procedure that enables the lumina of the uterine cavity and fallopian tubes to be outlined. Fundamentals in techniques have been stressed so as to limit the errors of omission and commission. During the course of many years, I have been honored by my colleagues, who have requested me to review interesting HSGs. Thus, I have been able to accumulate a series of x-rays that I can share with the readers of Modern Trends. Although these photographs seemed unique, many of them probably have been seen by other investigators. They are presented because of their important diagnostic features.

Developmentally arrested oviduct: a structural and functional defect in mice following prenatal exposure to diethylstilbestrol

To determine the effects of exposure to diethylstilbestrol (DES) on the developing oviduct, timed pregnant CD-1 mice were treated with DES (10-100 micrograms/kg subcutaneous) on days 9-16 of gestation. Prenatal DES-exposed and age-matched control mice were sacrificed from day 16 of gestation to 15 weeks of age and oviductal development was compared. Following prenatal exposure to DES (100 micrograms/kg), the oviduct at all ages examined was uncoiled and shorter, closely adherent to and wrapped around the ovary in an anatomical configuration similar to the fetal mouse. In addition, the demarcation between the oviduct and uterus was not readily apparent. Histological changes in the DES (100 micrograms/kg) oviduct as compared with control at 10-15 weeks of age included a proliferation of columnar epithelium lining the lumen with gland formation extending into the underlying stroma, absence of or a reduced amount of fimbrial tissue, increased thickness of the muscular wall, and inflammatory cell infiltration. Also, as a functional test of uterotubal junction integrity, Coomassie Blue dye was injected into the uterus. The control uterotubal junction confined the fluid to the uterus. In 80% and 100% of the animals exposed prenatally to DES (10 and 100 micrograms/kg, respectively), independent of the extent of the gross abnormality, the dye readily flowed into the oviduct and filled the ovarian bursa. We conclude that prenatal DES exposure can alter fetal development of the mouse oviduct, resulting in an apparent developmental arrest and functional disruption of the integrity of the uterotubal junction. The fetal like configuration of the ovary, oviduct, and uterus suggests the term developmentally arrested oviduct (DAO).

In utero exposure to diethylstilbestrol: adverse effects on the reproductive tract and reproductive performance and male and female offspring

Exposure to diethylstilbestrol (DES) in utero is associated with adverse effects on the reproductive tract in male and female progeny. These effects include epididymal cysts, microphallus, cryptorchidism, and testicular hypoplasia in male subjects and adenosis, clear cell adenocarcinoma, and structural defects of the cervix, vagina, uterus, and fallopian tubes in female subjects. As these offspring have reached reproductive age, reports of adverse reproductive performance have been published, including still controversial reports of menstrual dysfunction and infertility. More well established are increased rates of spontaneous abortion, ectopic pregnancy, premature deliveries, and perinatal deaths, all contributing to an increase in overall adverse pregnancy outcome. Often there is correlation between the DES-associated anatomic abnormalities in the reproductive tract and the adverse reproductive performance. Altered male reproductive capacity is also suggested by diminished semen analyses and sperm penetration assays. A detailed review of these effects of in utero DES exposure is presented.