The field of Reproductive Endocrinology and Infertility
is constantly evolving and changing. Innovations in diagnostic
tools and treatments occur regularly. At the California Center for Reproductive Health we are committed to remaining on the cutting
edge of our field. We engage regularly in research and
literature reviews in order to improve our understanding
of fertility and infertility. As new research is revealed, we
scrutinize it and look for additional supporting evidence.
When deemed applicable, new safe and beneficial tools for diagnosis
and treatment are applied in our daily practice to improve outcomes
for our patients. Below you will find a synopsis of this
month's chosen "Article of the Month". Please feel free to
contact us by e-mail should you have any unanswered questions.
Article of the Month:
TITLE: Endometrial receptivity is preserved in Diethylstilbestrol-associated and other Müllerian anomalies: Evidence from tubal embryo transfer
AUTHORS: Eliran Mor, MD et al
PLACE OF STUDY: University of Southern California Keck School of Medicine
PUBLICATION: Journal of Assisted Reproduction and Genetics
PUBLICATION DATE: January 2009
ABSTRACT:
Background and Synopsis of Findings:
It has previously been documented that women with uterine anomalies who undergo assisted reproduction (ART) have reduced implantation rates following standard transcervical embryo transfer. The Müllerian system is responsible for the development of the female uterus. The development of the Müllerian system and thus the uterus had been known to be abnormally affected when fetuses were exposed to diethylstilbestrol (DES), which was ingested by expecting mothers between 1938 and 1971. Sporadic, unexplained uterine anomalies, such as septate uterus (uterine septum), bicornuate uterus, uterus didelphys, and T-shaped uterus, may also occur of multifactorial causes. Because uterine anomalies may be associated with a suboptimal transcervical embryo transfer following in vitro fertilization (IVF), making the embryo transfer procedure more challenging and thus potentially decreasing the likelihood of implantation and pregnancy, the authors evaluated outcomes after laparoscopic transfer of embryos directly into the fallopian tubes (tubal embryo transfer=TET) in a specific subset of infertile women who had previously been diagnosed with a uterine anomaly. In this procedure, women underwent ovarian hyperstimulation with injectable hormones (gonadotropins) to stimulate the growth of multiple follicles. They next underwent a standard transvaginal ultrasound-guided follicle aspiration (egg retrieval procedure). Retrieved eggs were fertilized with sperm, and 24-48 hours after egg retrieval, patients underwent a laparoscopic procedure where 1-2 day old embryos were gently placed directly into the fallopian tubes, where early embryos naturally spend time in the first 5-6 days after conception. This procedure may sometimes be called zygote intrafallopian transfer (ZIFT).
The authors describe 7 women who underwent 12 TET procedures between 1995 and 2003. They reported that of the 7 women, 5 had previously experienced a total of 15 prior failed IVF cycles using a standard transcervical embryo transfer. The 12 TET procedures resulted in a 92% clinical pregnancy rate, and 7 deliveries of live babies (58%)!
WHAT DR. MOR THINKS::
The diagnosis of a uterine anomaly may be done using various procedures such as transvaginal ultrasound examination, hysterosalpingogram (HSG), sonohysterogram (SGH), magnetic resonance imaging (MRI), or laparoscopy. Some uterine anomalies, such as septate uterus, can be surgically corrected however; a T-shaped anomaly may still remain. Other uterine anomalies are often not amendable to surgical repair. In women with a uterine anomaly who require assisted reproduction (ART), a standard transcervical embryo transfer should be attempted first, because it is less invasive and less costly than a laparoscopic embryo transfer such as ZIFT or TET. If however transcervical embryo transfer fails, a laparoscopic approach should be seriously considered. In the small subset of women with a uterine anomaly also affecting the cervix, if the cervix is severely stenosed or abnormal, precluding a transcervical embryo transfer, a ZIFT or TET should be approached first.
