Localization of Bcl-2 in the human fetal müllerian tract

High incidence of imperforate vagina in ADGRA3-deficient mice

BACKGROUND

Ten percent of the female population suffers from congenital abnormalities of the vagina, uterus, or oviducts, with severe consequences for reproductive and psychological health. Yet, the underlying causes of most of these malformations remain largely unknown. ADGRA3 (GPR125) is involved in WNT signaling and planar cell polarity, mechanisms vital to female reproductive tract development. Although ADGRA3 is a well-established spermatogonial stem cell marker, its role within the female urogenital system remains unclear.

RESULTS

In this study, we found Adgra3 to be expressed throughout the murine female urogenital system, with higher expression pre-puberty than after sexual maturation. We generated a global Adgra3-/- mouse line and observed imperforate vagina in 44% of Adgra3-/- females, resulting in distension of the reproductive tract and infertility. Ovarian morphology, plasma estradiol, ovarian Cyp19a1, and vaginal estrogen receptor α (Esr1) expression were unaffected. However, compared to controls, a significantly lower bone mineral density was found in Adgra3-/- mice. Whereas vaginal opening in mice is an estrogen-dependent process, 17β-estradiol treatment failed to induce vaginal canalization in Adgra3-/- mice. Furthermore, a marked reduction in vaginal and ovarian progesterone receptor expression was observed concomitant with an upregulation of apoptotic regulators Bcl2, Bid, and Bmf in adult Adgra3-/- females with a closed vagina.

CONCLUSIONS

Our collective results shed new insights into the complex mechanisms by which the adhesion receptor ADGRA3 regulates distal vaginal tissue remodeling during vaginal canalization via altered sex hormone responsiveness and balance in apoptotic regulators. This highlights the potential of ADGRA3 as a target in diagnostic screening and/or therapy for obstructive vaginal malformations in humans.

Müllerian Duct Anomalies and Anti-Müllerian Hormone Levels in Women With Polycystic Ovary Syndrome

BACKGROUND

Significant associations between the presence of polycystic ovary syndrome (PCOS) and uterine anomalies have been reported. It is unclear whether high anti-Müllerian hormone (AMH) levels coexist with the development of uterine malformations in women with PCOS. This study sought to investigate the association between Müllerian duct anomalies and anti-Müllerian hormone (AMH) levels in women with PCOS.

METHODS

In this retrospective cohort study, the records of 1,391 women with PCOS were analyzed. The cohort was divided into a low-AMH group (n = 700) and a high-AMH group (n = 691), based on an AMH cutoff value of 8.45 ng/ml. Müllerian duct anomalies were classified into four subtypes based on three-dimensional ultrasonography: septate uterus, bicornuate uterus, uterus didelphys, unicornuate uterus, and arcuate uterus. The primary outcome was the overall incidence of Müllerian duct anomalies. The secondary outcome was the prevalence of the abovementioned specific types of Müllerian duct anomalies. The prevalence of Müllerian duct anomalies was analyzed using the chi-squared test or Fisher's exact test.

RESULTS

Among the patients with PCOS, the prevalence of unicornuate uterus anomalies was higher in the high-AMH group than in the low-AMH group (1.0% vs. 0.1%, P = 0.04). No statistically significant difference in the overall incidence of uterine malformations was found between the two AMH groups (4.3% vs. 5.7%, P = 0.22).

CONCLUSIONS

Our study confirmed a higher prevalence of unicornuate uterus in PCOS women with high AMH levels. Clinicians might decide to investigate the possibility of a unicornuate uterus in PCOS women with high AMH levels.

ADAMTS18 regulates vaginal opening through influencing the fusion of Mullerian duct and apoptosis of vaginal epithelial cells in mice

The ADAMTS (A Disintegrin and Metalloproteinase with Thrombospondin Motifs) enzymes are secreted metalloproteinases with major roles in development, morphogenesis, and tissue repair via the assembly and degradation of extracellular matrix (ECM). In this study, we investigated the role of ADAMTS18 in the development of the reproductive tract in female mice by phenotyping Adamts18 knockout (Adamts18^-/-) mice. The results showed that Adamst18 mRNAs were abundantly expressed in vaginal epithelial cells and muscularis cells of the developing vagina. At the time of vaginal opening (5 weeks of age), about 41 % of Adamts18^-/- females showed enlarged protrusions in the upper and middle parts of the vagina, reduced vaginal length, and simultaneously exhibited vaginal atresia. 6% Adamts18^-/- females exhibited vaginal septum. Histological analyses revealed that the paired Mullerian ducts in ∼33 % female Adamts18^-/- embryos failed to fuse at embryonic day 15.5 (E15.5) resulting in the formation of two vaginal cavities. Results of TUNEL assay and immunohistochemistry for caspase-3 showed that the number of apoptotic cells in the terminal portion of the vagina of 5-week-old Adamts18^-/- females with vaginal atresia was significantly decreased. Adamts18^-/- females also showed a significant decrease in serum estradiol E2 compared to age-matched Adamts18^+/+ females. Results of qRT-PCR showed that the expression level of the anti-apoptosis gene Bcl-2 was significantly increased and that of the apoptosis-related gene Epha1 was decreased in the vagina of 5-week-old Adamts18^-/- females. These results suggest that ADAMTS18 regulates vaginal opening through influencing the fusion of Mullerian ducts and apoptosis of vaginal cells in mice.

Does hysteroscopic resection of uterine septum improve reproductive outcomes: a systematic review and meta-analysis

PURPOSE

Uterine septum in women with subfertility or previous poor reproductive outcomes presents a clinical dilemma. Hysteroscopic septum resection has been previously associated with adverse reproductive outcomes but the evidence remains inconclusive. We aimed to thoroughly and systematically appraise relevant evidence on the impact of hysteroscopically resecting the uterine septum on this cohort of women.

METHODS

AMED, BNI, CINAHL, EMBASE, EMCARE, Medline, PsychInfo, PubMed, Cochrane register of controlled trials, Cochrane database of systematic reviews and CINAHL were assessed to April 2020, with no language restriction. Only randomised control trials and comparative studies which evaluated outcomes in women with uterine septum and a history of subfertility and/or poor reproductive outcomes treated by hysteroscopic septum resection against control were included. The primary endpoint was live birth rate, whereas clinical pregnancy, miscarriage, preterm birth and malpresentation rates were secondary outcomes.

RESULTS

Seven studies involving 407 women with hysteroscopic septum resection and 252 with conservative management were included in the meta-analysis. Hysteroscopic septum resection was associated with a lower rate of miscarriage (OR 0.25, 95% CI 0.07-0.88) compared with untreated women. No significant effect was seen on live birth, clinical pregnancy rate or preterm delivery. However, there were fewer malpresentations during labour in the treated group (OR 0.22, 95% CI 0.06-0.73).

CONCLUSION

Our review found no significant effect of hysteroscopic resection on live birth. However, given the limited evidence available, high-quality randomised controlled trials are recommended before any conclusive clinical guidance can be drawn.

The development of the human uterus: morphogenesis to menarche

There is emerging evidence that early uterine development in humans is an important determinant of conditions such as ontogenetic progesterone resistance, menstrual preconditioning, defective deep placentation and pre-eclampsia in young adolescents. A key observation is the relative infrequency of neonatal uterine bleeding and hormone withdrawal at birth. The origin of the uterus from the fusion of the two paramesonephric, or Müllerian, ducts was described almost 200 years ago. The uterus forms around the 10th week of foetal life. The uterine corpus and the cervix react differently to the circulating steroid hormones during pregnancy. Adult uterine proportions are not attained until after puberty. It is unclear if the endometrial microbiome and immune response-which are areas of growing interest in the adult-play a role in the early stages of uterine development. The aim is to review the phases of uterine development up until the onset of puberty in order to trace the origin of abnormal development and to assess current knowledge for features that may be linked to conditions encountered later in life. The narrative review incorporates literature searches of Medline, PubMed and Scopus using the broad terms individually and then in combination: uterus, development, anatomy, microscopy, embryology, foetus, (pre)-puberty, menarche, microbiome and immune cells. Identified articles were assessed manually for relevance, any linked articles and historical textbooks. We included some animal studies of molecular mechanisms. There are competing theories about the contributions of the Müllerian and Wolffian ducts to the developing uterus. Endometrium features are suggestive of an oestrogen effect at 16-20 weeks gestation. The discrepancy in the reported expression of oestrogen receptor is likely to be related to the higher sensitivity of more recent techniques. Primitive endometrial glands appear around 20 weeks. Features of progestogen action are expressed late in the third trimester. Interestingly, progesterone receptor expression is higher at mid-gestation than at birth when features of endometrial maturation are rare. Neonatal uterine bleeding occurs in around 5% of neonates. Myometrial differentiation progresses from the mesenchyme surrounding the endometrium at the level of the cervix. During infancy, the uterus and endometrium remain inactive. The beginning of uterine growth precedes the onset of puberty and continues for several years after menarche. Uterine anomalies may result from fusion defects or atresia of one or both Müllerian ducts. Organogenetic differentiation of Müllerian epithelium to form the endometrial and endocervical epithelium may be independent of circulating steroids. A number of genes have been identified that are involved in endometrial and myometrial differentiation although gene mutations have not been demonstrated to be common in cases of uterine malformation. The role, if any, of the microbiome in relation to uterine development remains speculative. Modern molecular techniques applied to rodent models have enhanced our understanding of uterine molecular mechanisms and their interactions. However, little is known about functional correlates or features with relevance to adult onset of uterine disease in humans. Prepubertal growth and development lends itself to non-invasive diagnostics such as ultrasound and MRI. Increased awareness of the occurrence of neonatal uterine bleeding and of the potential impact on adult onset disease may stimulate renewed research in this area.

The prevalence of uterine anomalies in infertile patients with polycystic ovary syndrome: A retrospective study in a tertiary center in Southeastern Turkey

Objective:

To evaluate the prevalence of uterine anomalies in infertile patients with polycystic ovary syndrome (PCOS) admitted to our tertiary hospital in Southeastern Turkey.

Materials and Methods:

The files of 3033 patients with infertility who presented to the infertility polyclinics were retrospectively analyzed, and uterine anomalies were detected in 131 patients. Seven hundred ten of these patients were evaluated as having PCOS, 55 of whom had uterine anomalies. Patients with PCOS were also divided into two subgroups as those with primary and secondary infertility.

Results:

Of the 3033 patients with infertility who were evaluated, 57 (8%) of 710 infertile patients with PCOS, and 74 (3%) of 2323 non-PCOS patients with infertility had uterine anomalies. A statistically significant difference was found between the two groups (p<0.001), and no significant difference was found between the primary and secondary infertile PCOS subgroups (p=0.3). Septate uteri and arcuate uteri had a high prevalence in the PCOS group, and no t-shaped or hypoplastic uteruses were observed in this group.

Conclusion:

To or knowledge, this is the first study in our region to examine the relation between PCOS and Müllerian anomalies. We demonstrated uterine anomalies and their prevalence in patients with infertility. A more careful examination is required in order to determine the incidence of uterine anomalies in patients with PCOS.

Sequence variant in the CDC42BPB gene is potentially associated with Mullerian duct anomalies

AIM

Mullerian duct anomalies (MDA) are common female genital tract malformations. Genetic and environmental factors are important causes of MDA in women. Although many genes and mutations have been found to be associated with the pathogenesis of MDA, in most cases, the genetic pathogenic factors of MDA are still unknown.

METHODS

We first analyzed the three sisters using low coverage whole-genome sequencing. Then whole-exome sequencing was carried out in each patient. The identified sequence variant was confirmed by Sanger sequencing. In silico pathogenicity analysis and conservative analysis of the mutation site were also performed. Protein structural modeling was used to analyze the effect of the mutated amino acid.

RESULTS

We first analyzed the three sisters with septate uterus using low coverage whole-genome sequencing, but no possible pathogenic copy number variation was found. Then whole-exome sequencing was performed on the three sisters, and a rare homozygous variant, CDC42BPB:c.2012G>A:p.R671Q, was identified. All three patients were found with this variant. Sanger sequencing validated that this variant was segregated within the family. In silico pathogenicity analysis and conservative analysis of the mutation site suggested that the variant might be damaging. Protein structural analysis suggested that R671Q might weaken the electrostatic potential of this region, which may be a significant regulation target or protein interaction surface of CDC42BPB.

CONCLUSION

We demonstrated that CDC42BPB genetic variant might be potentially associated with the pathogenesis of MDA.

Uterine factors

Uterine anomalies are one of the most common parental causes of recurrent pregnancy loss, occurring in about 19% of patients. Congenital uterine anomalies are most likely caused by HOX gene mutations, although the mechanism is probably polygenic. There are no known environmental causes other than estrogenic endocrine disruptors such as diethylstilbestrol. Acquired uterine anomalies may result from uterine trauma (adhesions) or benign growths of the myometrium (fibroids) or endometrium (polyps). Although randomized controlled trials are lacking, surgical treatment is recommended for repair of uterine septa, and for removal of severe adhesions and submucosal fibroids, especially if no other causes are identified.

Lhx1 is required in Müllerian duct epithelium for uterine development

The female reproductive tract organs of mammals, including the oviducts, uterus, cervix and upper vagina, are derived from the Müllerian ducts, a pair of epithelial tubes that form within the mesonephroi. The Müllerian ducts form in a rostral to caudal manner, guided by and dependent on the Wolffian ducts that have already formed. Experimental embryological studies indicate that caudal elongation of the Müllerian duct towards the urogenital sinus occurs in part by proliferation at the ductal tip. The molecular mechanisms that regulate the elongation of the Müllerian duct are currently unclear. Lhx1 encodes a LIM-homeodomain transcription factor that is essential for male and female reproductive tract development. Lhx1 is expressed in both the Wolffian and Müllerian ducts. Wolffian duct-specific knockout of Lhx1 results in degeneration of the Wolffian duct and consequently the non-cell-autonomous loss of the Müllerian duct. To determine the role of Lhx1 specifically in the Müllerian duct epithelium, we performed a Müllerian duct-specific knockout study using Wnt7a-Cre mice. Loss of Lhx1 in the Müllerian duct epithelium led to a block in Müllerian duct elongation and uterine hypoplasia characterized by loss of the entire endometrium (luminal and glandular epithelium and stroma) and inner circular but not the outer longitudinal muscle layer. Time-lapse imaging and molecular analyses indicate that Lhx1 acts cell autonomously to maintain ductal progenitor cells for Müllerian duct elongation. These studies identify LHX1 as the first transcription factor that is essential in the Müllerian duct epithelial progenitor cells for female reproductive tract development. Furthermore, these genetic studies demonstrate the requirement of epithelial-mesenchymal interactions for uterine tissue compartment differentiation.

The vaginal spindle cell epithelioma: a case report, review of the literature and discussion of potential histogenesis

The so-called mixed tumors occur in a variety of sites throughout the body. While most cases are encountered in the salivary glands, several cases have been described in the female genital tract. A variety of monikers have been applied to this lesion including "spindle cell epithelioma." As in other locations, the vaginal spindle cell epithelioma (VSE) consists of a proliferation of both epithelial and mesenchymal components. Based on our extensive review of the literature, we present the 53rd reported case of VSE. More significantly, we present the most up-to-date review of this lesion, including its immunohistochemical and electron microscopic features. We also review the theories pertaining to its histogenesis incorporating current embryologic data, which together suggest a Müllerian derivation.

An adolescent affliction: nephrectomy and persistent severe pains due to misdiagnosed non-communicating "retroperitoneal" uterine horn

STUDY OBJECTIVE

To report the existence and management of retroperitoneal functioning uterine horn in a case with unicornuate uterus and to emphasis the significance of its misdiagnosis.

STUDY DESIGN

Case report.

SETTING

Assiut University, Woman's Health Hospital.

PARTICIPANTS

An adolescent female with progressive pains related to menstruation.

INTERVENTIONS

Extraperitoneal resection of the obstructed uterine horn.

MAIN OUTCOME MEASURE

Operative time, complications and postoperative pains.

RESULTS

A patient aged 11 years presented with severe lower abdominal pains, history of correction of ectopia vesicae in infancy, and recent history of nephrectomy for ipsilateral obstructed pelvic kidney. MRI and transrectal ultrasonography showed a pelvic mass with thick wall. Laparoscopy showed unicornuate uterus with only the left horn was being visualized. Hysteroscopy showed normal vagina and cervical canal communicating with normal left hemi-cavity. Extraperitoneal approach via extending the incision of previous nephrectomy was done under laparoscopic monitoring. Excision of the horn was done totally extraperitoneal without puncturing its covering parietal peritoneum within 65 min. No operative or postoperative complications were reported. Menstrual pains showed dramatic improvement after the procedure.

CONCLUSIONS

The present report is the first to describe the existence of a retroperitoneal functioning uterine horn with description of a successful extraperitoneal approach for its excision. Nephrectomy in the present case might be attributed to misdiagnosis of this problem.

Twin Gestation in a Septate Bicornuate Uterus

Bicornuate and septate uteri are among the commonest Mullerian anomalies. They are sporadic and fairly distinguished, but hybrid deformities can occur. This combination creates aetiological and clinical difficulties. The alternative theory of concurrent fusion and septal resorption of the Mullerian duct is seen as the basis of the altered foetal embryology, while the favourable outlook of a bicornuate uterus may be offset by the suboptimal implantation across the avascular septum. Obstetric care is based on empirical interventions deduced from case series, with varied and inconsistent outcomes. We present a 32-year-old primipara with a dizygotic twin gestation in separate compartments of a septate bicornuate uterus. She had an elective bilateral caesarean delivery at term with an accidental septal resection for morbidly adherent placenta. Although a summation of obstetric risks is a possibility, an excellent outcome was observed.

Congenital uterine anomalies and their impact on fertility

Congenital uterine anomalies are not uncommon. Many are asymptomatic and have been associated with normal and adverse reproductive outcomes. The interference of these anomalies with a patient's fertility is an interesting but still debatable issue, and the proper management of infertile women with many forms of these anomalies remains controversial. The current literature regarding the frequency and probable causes of infertility among women with congenital uterine anomalies is insufficient to allow any robust conclusions to be drawn. Diagnostic and selection bias, a lack of objective diagnostic criteria for the different anomaly types and heterogeneity of study designs have contributed to the conflicting results from different studies of the prevalence of these anomalies among the infertile and fertile populations. However, emerging evidence from recent literature suggests causal associations between these anomalies (particularly the septate uterus) and infertility, and demonstrates significant improvements in the fecundity of women with septate uteri and otherwise unexplained infertility after hysteroscopic metroplasty. This review provides a critical update of the state of knowledge regarding congenital uterine anomalies, our current understanding of their effect on fertility and discusses how they can be managed from the reproductive perspective.

[Septate uterus: role of hysteroscopic metroplasty]

The uterus septum is the most frequently encountered uterine malformation. The prevalence of the uterine septa in the infertile patients is estimated at approximately 1%. On the other hand, it increases to reach 3,3% among women presenting repeated fetal losses. The objective of this article is to propose an updating of the data of the literature concerning the cure of uterine septa by hysteroscopic metroplasty. Operative hysteroscopy, with its simplicity, its reproducibility and its low morbidity between the hands of a trained operator, remains the gold standard treatment of the uterine partitions. The abortive disease always constitutes the main indication of the cure of septum. In the infertile patients, a metroplasty seems to be legitimate in the following situations: women more than 35 years old; unexplained infertility, resistant to any technique of assisted reproduction; discovery of a uterine septum at the time of the coelioscopy and the diagnostic hysteroscopy realized within the framework of an assessment of infertility; patients for whom it is assumed that Assisted reproductive technique (ART) is needed; women with past obstetrical history. The complications related to the hysteroscopic metroplasty are not very frequent. However, the hysteroscopic resection of a uterine septum could expose later to the risk of uterine rupture.

Ultrastructural dynamics of the human endometrium from 14 to 22 weeks of gestation

In order to elucidate the ultrastructural dynamics of endometrium differentiation, uterine samples of fetuses aged 14 to 22 weeks of gestation (WG) were analyzed. Samples were processed for light (LM), transmission (TEM) and field-emission scanning electron microscopy (FE-SEM). Initial stratification of the uterine wall occurred at 14 WG: endometrial, myometrial, and perimetrial primordia were identified. At this age, the endometrial epithelium was simple columnar to pseudostratified and consisted of microvillous cells. Blood capillaries developed mainly in the stroma and between the myometrium and perimetrium primordia. At 18-20 WG the endometrial epithelium became clearly pseudostratified, with active ciliogenesis and a predominance of microvillous cells. Primordia of tubular glands were present at 20 WG. Microvillous cells still predominated in the endometrial epithelium at 21-22 WG and showed morphological features of apoptosis. The endometrial stroma at this stage was organizing into a thick lamina propria provided with subepithelial capillary plexuses. However, the stroma was formed by still undifferentiated mesenchymal cells during the whole period of study. Our data showed that the epithelial differentiation and distribution in the uterus occur in the human fetus in a similar way as in the adult. The above events are likely the expression of an early developmental patterning and related to future reproductive processes, such as the regulation of gamete passage and blastocyst implantation. Because the structure of the adult uterus is determined by the degree of paramesonephric duct fusion, septum absorption, and differentiation of the uterine primordial layers, our study may contribute toward clarifying to normal urogenital development.

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.

Hysteroscopic Metroplasty Improves Gestational Outcome in Women with Recurrent Spontaneous Abortion

STUDY OBJECTIVE

To compare the reproductive outcome in women with recurrent spontaneous abortion (RSA) associated with septate uterus after hysteroscopic metroplasty compared with patients who did not undergo surgery.

DESIGN

Longitudinal evaluation (Canadian Task Force classification II-2).

SETTING

University of Rome, Tor Vergata-affiliated endoscopic unit.

PATIENTS

Forty-eight consecutive women with septate uterus and RSA were enrolled in the study.

INTERVENTIONS

Hysteroscopic metroplasty.

MEASUREMENTS AND MAIN RESULTS

Reproductive outcome in terms of term pregnancy was significantly improved after hysteroscopic metroplasty compared with controls (76% vs. 20%). No differences were found in the prevalence of preterm delivery between groups (4% vs. 5%).

CONCLUSION

Our data suggest that hysteroscopic septum incision can improve pregnancy outcome in patients with RSA associated with septate uterus.

Lifetime expression of stem cell markers in the uterine endometrium

OBJECTIVE

To identify stem cells in uteri from the fetal to the postmenopausal period.

DESIGN

Descriptive, controlled study.

SETTING

Tertiary academic medical center.

PATIENT(S)

Forty archived uterine endometrial samples.

INTERVENTION(S)

Immunohistochemistry with c-kit/CD117, CD34, bcl-2, and Ki67.

MAIN OUTCOME MEASURE(S)

Immunostaining.

RESULT(S)

C-kit/CD117, CD34, bcl-2, and Ki67 were consistently expressed in the stroma of the basalis layer. Bcl-2 was restricted to the fetal uterine endometrium.

CONCLUSION(S)

By studying the immunolocalization of stem cell markers (i.e., c-kit, CD34, and bcl-2), we found that stem cells are present continuously in the uterine endometrium from the fetal period. The cells seem to be located mainly in the stroma of the basalis and to be independent of hormonal regulation to avoid cyclic shedding. A small number of latent stem cells dormant in the stroma of the basalis were found to have the potential for mesenchymal differentiation.

[Septate uterus and reproduction disorders: current results of hysteroscopic septoplasty]

Uterus septus is the most frequent congenital uterine anomalies caused by insufficient resorption of the müllerian ducts. Retrospective statistical analysis shows that the uterine septa have the worst reproductive outcome with a high incidence of early abortions. It is well recognized that it increased the incidence of recurrent (> or = 3) miscarriages (79% among 1,601 pregnancies), reproductive failure and obstetric complications. A septate uterus does not seem to be an infertility factor. On the other hand, the incidence of unexplained infertility was significantly higher (40%) in the patients with secondary infertility; thus, a contribution from the uterine septum in delayed conception of these patients cannot be excluded. Hysteroscopic surgery has replaced conventional abdominal route. Hysteroscopic metroplasty improves obstetrical prognosis in women with septate uterus, and it's advantages are easiness, low morbidity rate, without the hysterotomy's consequences like adnexial adhesions. Metroplasty is indicated in women with a history of miscarriages (2 or more), which decreased to 15%, in patients with an unexplained infertility, and in women in whom assisted reproductive treatment is being contemplated. Combined with laparoscopy, the hysteroscopic metroplasty is the gold standard for assessing uterine septa, especially in these infertile women. Laparoscopy also is required to complete the diagnostic work up of infertility, and provides an opportunity to treat any coexisting pelvic pathology.

Evidence for a suppression of apoptosis in early postnatal life

BACKGROUND

In fetal life the rates of proliferation and apoptosis are high. We studied if the rate of apoptosis decreases after birth, by measuring the soluble (s) forms of Fas-Fas ligand and Tumor necrosis factor receptor 1 (TNFR1)-TNF-alpha which attenuate apoptosis.

SUBJECTS AND METHODS

Blood was drawn from the umbilical cord and from a peripheral vein on day 1 and 4 of life in 35 infants and sFas, sFas ligand, sTNFR1 and sTNF-alpha were determined by enzyme immunoassays. Data were analyzed by paired t-test and Pearson's correlation analysis.

RESULTS

sFas and sTNF increased significantly from birth to day 4 of life (p=0.033 and p<0.0001 respectively), while sTNFR1 increased significantly from birth to day 1 of life (p<0.0001) followed by a significant decrease on day 4 of life (p<0.0001). The levels of sFas and sTNF-alpha on day 1 correlated with those on day 4 (r=0.677, p<0.0002 and r=0.525, p<0.007 respectively). sFAS ligand was not detectable in any specimen.

CONCLUSION

The increasing concentrations of the soluble molecules, sFas, sTNF-alpha and sTNFR1 might indicate that apoptosis may be downregulated in early postnatal life.

Clinical implications of sonographic detection of uterine anomalies for reproductive outcome

The purpose of this review article was to analyze the literature on the prevalence, diagnosis and treatment of the congenital uterine anomalies and to discuss current dilemmas on their influence on reproductive outcome. Congenital uterine anomalies are commonly associated with repeated pregnancy failure, in particular an increased risk of first- and second-trimester miscarriages and preterm delivery. Recent reports on two-dimensional and three-dimensional transvaginal ultrasound and saline contrast sonohysterography appear promising for diagnosis and classification of congenital uterine anomalies. The ability to visualize both the uterine cavity and the fundal uterine contour on a three-dimensional scan facilitates the diagnosis of uterine anomalies and enables differentiation between septate and bicornuate uteri. Color Doppler ultrasound allows visualization of intraseptal vascularity and may help in distinguishing the avascular from the vascular septum. Less connective tissue in the septum may result in poor decidualization and placentation, while an increased amount of muscle tissue in the septum can cause miscarriage by the production of local uncoordinated myometrial contractility. Hysteroscopic septum excision is an effective procedure which improves live-birth rates. Because of its simplicity, minimal invasiveness, low morbidity and low cost, a more liberal approach to the treatment of uterine anomalies is being advocated.

The septate uterus: a review of management and reproductive outcome

OBJECTIVE

To review the literature on the diagnosis, prevalence, and treatment of the septate uterus, with special reference to hysteroscopic metroplasty and its effect on reproductive outcome.

DESIGN

Pertinent studies were identified through a computer MEDLINE search. References of selected articles were hand-searched for additional citations.

RESULT(S)

Reliable diagnosis of the septate uterus depends on accurate assessment of the uterine fundal contour. At present, the combined use of laparoscopy and hysteroscopy is the gold standard for diagnosis, although recent reports of two-dimensional, transvaginal, contrast ultrasound and of three-dimensional ultrasound appear promising. The prevalence of the septate uterus is increased in women with repeated pregnancy loss. A metaanalysis of published retrospective data comparing pregnancy outcome before and after hysteroscopic septoplasty indicated a marked improvement after surgery.

CONCLUSION(S)

The hysteroscopic approach to treatment, with its simplicity, minimal postoperative sequelae, and improved reproductive outcome, has enabled a more liberalized approach to treatment that is now being extended to include not only patients with recurrent pregnancy loss and premature labor but also patients with infertility, especially if IVF is being contemplated.

The role of apoptosis in normal and abnormal embryonic development

Programmed cell death or apoptosis is a widespread biological phenomenon. Apoptosis is characterized by typical cell features such as membrane blebbing, chromatin condensation, and DNA fragmentation. It involves a number of membrane receptors (e.g., Fas, TNFR) and a cascade of signal transduction steps resulting in the activation of a number of cysteine proteases known as caspases. Disordered apoptosis may lead to carcinogenesis and participates in the pathogenesis of Alzheimer disease, Parkinson disease, or AIDS. Programmed cell death plays an important role in the processes of gamete maturation as well as in embryo development, contributing to the appropriate formation of various organs and structures. Apoptosis is one of the mechanisms of action of various cytotoxic agents and teratogens. Teratogen-induced excessive death of embryonic cells is undoubtedly one of the most important events preceding the occurrence of structural abnormalities, regardless of their nature. Therefore understanding the mechanisms involved in physiological as well as in disturbed or dysregulated apoptosis may lead to the development of new methods of preventive treatment of various developmental abnormalities. The present review summarizes data on the mechanisms of programmed cell death and concentrates on apoptosis involved in normal or disturbed gametogenesis and in normal and abnormal embryonic development.