DES Daughters - A look forward with Gestational Surrogacy

Daughters exposed to DES during prenatal development may have several abnormalities in the reproductive tract.(1,2) Some of these abnormalities are associated with the cervix and vagina, including clear cell vaginal carcinoma and an abnormally-shaped cervix. However, those problems most important for pregnancy involve the upper reproductive tract - the uterus and Fallopian tubes. These may include hypoplasia (underdevelopment) of the uterus and tubes, a T-shaped uterus, constriction of the upper, middle, or cornual regions of the uterus, and irregular uterine margins.

A DES daughter may have no symptoms or problems until she attempts pregnancy, and only then be diagnosed with one or more of these abnormalities. A physical exam may show abnormalities of the cervix that could alert the physician to potential problems in the upper reproductive tract. A hysterosalpingogram (X-ray of the uterus and Fallopian tubes) is the clearest way to diagnose a hypoplastic or T-shaped uterus. Though rarely necessary for this specifically, laparoscopy and/or hysteroscopy may sometimes be helpful in further diagnosing the potential abnormalities.

Medical studies in general indicate that there is no difference in pregnancy rates between DES daughters and women not exposed to DES in utero.(3,4) Some, however, report that up to 30% of women exposed to DES experience infertility.(5,6) All are in agreement that DES daughters are at significantly increased risk of poor pregnancy outcome. This seems to be especially the case for women with a hypoplastic or T-shaped uterus. It has been suggested that alterations in uterine blood supply, diminished uterine volume and capacitance (ability to stretch and enlarge), and defective uterine or cervical connective tissue may be to blame for these pregnancy-related problems. These problems include recurrent miscarriage, ectopic pregnancy, cervical incompetence (cervix dilating without labor), and premature labor.

DES daughters are estimated to be 8.6 times more likely to have an ectopic pregnancy, 1.8 times more likely to have a miscarriage, and 4.7 times more likely to have a premature birth than unexposed women.(1) Women with an abnormality of the cervix or uterus are 13.5 times more likely to have an ectopic pregnancy, 2.6 times more likely to have a miscarriage, and 9.6 times more likely to have a premature birth than unexposed women. Certainly this does not mean that DES daughters cannot and do not sometimes conceive and deliver normally, but the possibility of problems is very great.

One relatively recent study observed 120 pregnancies in DES-exposed women. Those with documented abnormalities of the reproductive tract had a 25.8% rate of miscarriage, versus 12.9% in those with no demonstrated abnormalities.(7) Of those pregnancies that continued past the first trimester, preterm labor occurred in 6.5%, preterm birth in 9.2%, and 92.2% delivered a viable infant.

Unfortunately these reproductive tract abnormalities do not generally respond well to corrective surgery. The decreased blood supply, defective connective tissue, etc. cannot often be improved. The good news is that none of these abnormalities involve the woman's ovaries. She can and does still ovulate normally, and can genetically mother a child as well as any other woman. Being DES-exposed does not alter the genetics, as far as we know, and there does not appear to be any significant risk of problems in DES granddaughters.

This is where surrogacy comes in. Certainly the classical surrogacy situation is an appropriate choice for couples where the wife is DES-exposed and may have difficulty delivering a child. But using a gestational surrogate is a truly ideal option. In this procedure, the DES daughter would be given drugs to stimulate her ovaries to produce a number of eggs. Using the IVF (in vitro fertilization) procedure, her eggs would be removed from her ovaries, fertilized with her husband's sperm, and the resulting embryos would be placed in the uterus of a gestational surrogate to carry the pregnancy. Because the DES daughter's problems with pregnancy are usually directly related to the uterine abnormalities, there is every reason to be hopeful that the resulting pregnancy in the gestational surrogate would be uncomplicated.

This author is unaware of any articles describing the success rates of pregnancy using eggs from DES daughters and a gestational surrogate. However, there is no good reason to believe that the success rate would be any different than in those couples using a gestational surrogate for other reasons. The most recent SART statistics (Society for Assisted Reproductive Technology) showed a 38% pregnancy rate per initiated cycle for gestational surrogacy.

Using a gestational surrogate seems to be the ideal solution for many couples troubled with pregnancy loss or infertility because of DES exposure. This allows both partners to be full genetic parents, while using another individual to provide a uterus to carry the developing child.

Each individual couple's circumstances are unique. Ask questions, and keep searching until you find what is right for you. And happy parenting!

References

1. Guisti RM, Iwamoto K, Hatch EE. Diethylstilbestrol revisited: a review of the long-term health effects. Ann Intern Med. 122;778, 1995.

2. Kaufman RH, Adam E, Burder GL, Gerthoffer. Upper genital tract changes and pregnancy outcome in offspring exposed in utero to diethylstilbestrol. Am J Obstet Gynecol. 137:299, 1980.

3. Barnes AB, Colton T, Gundersen J, et al. Fertility and outcome of pregnancy in women exposed in utero to diethylstilbestrol. N Engl J Med. 302:609, 1980.

4. Cousins L, Karp W, Lacey C, Lucas WE. Reproductive outcome of women exposed to diethylstilbestrol in utero. Obstet Gynecol. 56:70, 1980.

5. Schmidt G, Fowler WC Jr, Talbert LM, Edelman DA. Reproductive history of women exposed to diethylstilbestrol in utero. Fertil Steril. 33:21, 1980.

6. Herbst AL, Hubby MM, Blough RR, Azizi F. A comparison of pregnancy experience in DES-exposed and DES-unexposed daughters. J Reprod Med. 24:62, 1980.

7. Levine RU, Berkowitz KM. Conservative management and pregnancy outcome in diethylstilbestrol-exposed women with and without gross genital tract abnormalities. Am J Obstet Gynecol. 169:125, 1993. very special people. They are providing infertile couples with one last chance to be a family and have the child of their dreams. These women are even more special because not just any person can be a donor. While many women are physically able to donate their eggs, not everyone has the qualities necessary to make a suitable egg donor.

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