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PubMed2003

Ureteral endometriosis.

PURPOSE: This review discusses the pathophysiology, presentation, and different minimally invasive medical and surgical treatment options for ureteral endometriosis. MATERIALS AND METHODS: A comprehensive literature review of reports on the diagnosis and management of ureteral endometriosis was performed using MEDLINE. RESULTS: Ureteral endometriosis is a rare disease. Most cases present with silent obstruction, as opposed to cyclical hematuria. The diagnosis of ureteral endometriosis requires a high index of suspicion. A variety of diagnostic tests can help identify the extent of disease and the degree of renal function on the side of ureteral involvement. CONCLUSIONS: Ureteral endometriosis can be treated with hormones or surgical intervention. While surgery is reserved for hormone refractory cases and obstruction associated with extensive scarring, the majority of cases can be managed with hormones only. A combination of hormones and surgery is also effective. Surveillance for obstructive uropathy with periodic noninvasive monitoring of kidney function is currently recommended for all patients with endometriosis.

Danazol↗

PubMed2005

GSTM1, GSTT1 and CYP1A1 detoxification gene polymorphisms and their relationship with advanced stages of endometriosis in South Indian women.

OBJECTIVE(S): Studies on association between endometriosis and various phase I and phase II detoxification genes such as glutathione S-transferase M1 and theta 1 (GSTM1 and GSTT1) and cytochrome P450 (CYP1A1) have produced inconsistent results possibly because of ethnic differences. The present study was undertaken to investigate the frequency of the CYP1A1 (6235T>C) polymorphism and GSTM1, GSTT1 null mutations in a South Indian women's population with and without endometriosis. METHODS: The frequencies of variants were studied in 310 women with laparoscopically proven endometriosis (rAFS III=101; IV=209) and 215 women without endometriosis using the polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: The GSTM1 null deletion showed significant association (P=0.028) with endometriosis. No significant difference was found in the frequencies of the GSTT1 null deletion in cases and controls. The frequencies of the variant CYP1A1 homozygous and heterozygous alleles in the cases were 9% and 44.2% against 14.4% and 42.3% in the controls. Further, we observed a considerable difference in the GSTM1 null deletion frequency in this population when compared with other populations of the world. CONCLUSIONS: We observed an association between endometriosis and the GSTM1 null deletion, but not with GSTT1 null deletions or the CYP1A1 MspI polymorphism in South Indian women.

Adolescent↗

PubMed2005

A life shaped by pain: women and endometriosis.

AIMS AND OBJECTIVES: The research aim was to explore women's perceptions of living with endometriosis, its effects on their lives and the strategies used to manage their disease. BACKGROUND: Symptomatic endometriosis significantly affects women's quality of life. Characteristically the condition causes severe pain and has a negative impact on the ability to work, on family relationships and self-esteem. There has been little discussion about women's experience of endometriosis in nursing literature. DESIGN: A qualitative research design informed by feminist research principles was chosen for this project. METHODS: Eighteen women agreed to take part in the research. The individual, audio taped interviews were semi-structured and interactive. The interviews were analysed using a thematic analysis approach. RESULTS: The dominant feature of data from the interviews was the experience of severe and chronic pain impacting on all aspects of life. Analysis related to pain resulted in four themes: manifestations of pain, the pain trajectory, intractable pain and controlling pain. CONCLUSION: The diagnostic process typically took 5-10 years indicating that primary health care practitioners need higher levels of 'suspicion' for this condition. Case studies and problem-based scenarios focusing on endometriosis in health professional education programmes would enhance diagnostic skills and knowledge development. No formal pain management follow up after diagnosis and treatment meant women actively sought information from other sources as they made major lifestyle changes in the areas of activity and nutrition. Pain management services specifically for women with endometriosis would provide much needed support with this neglected aspect of the disease. RELEVANCE TO CLINICAL PRACTICE: This is a fertile area for the development of the Nurse Practitioner role which, also drawing on the considerable collective expertise of women with endometriosis, could provide significant information and support for women as they manage this highly complex condition.

Activities of Daily Living↗

PubMed1990

Gonadotrophin releasing hormone agonist (buserelin) in the treatment of endometriosis: changes in the extent of the disease and in CA 125 serum levels after 6-month therapy.

Twenty-two women with endometriosis were treated with the luteinizing hormone-releasing hormone (LHRH) agonist buserelin for 6 months. At second-look laparoscopy the mean score of endometriosis had decreased from 23.1 (SD 17.0) to 17.2 (SD 20.2) (P less than 0.05). CA 125 serum levels decreased from 38.4 (SD 32.2) U/ml at diagnosis to 15.5 (SD 7.0) at second look (P less than 0.005). CA 125 levels correlated at diagnosis with total score of endometriosis (P less than 0.05) and with active score of endometriosis (P less than 0.05), but not with the adhesion score. CA 125 levels were not correlated with endometriosis scores at second look laparoscopy, thus suggesting that mechanisms other than the change in the extent of the disease may be involved in the CA 125 decrease during therapy. CA 125 levels may therefore not be a reliable indicator for monitoring the efficacy of LHRH agonist treatment of endometriosis.

Adult↗

PubMed1991

Autoreactivity in women with endometriosis.

Serum samples from 71 patients with laparoscopically staged endometriosis and from 109 age-matched non-pregnant control women were tested for antibodies to nuclear, phospholipid, smooth muscle and sperm antigens. Immunoglobulin G, M and A and complement components C3 and C4 were measured. Prevalence of the following autoantibodies was statistically significantly greater in women with endometriosis than in the control group: antinuclear antibodies, antibodies to ribonucleoproteins, smooth muscle antibodies, lupus anticoagulant and anticardiolipin antibody. Forty-one women with endometriosis (58%) had some type of autoantibody compared with 13 controls (12%). More women in the endometriosis group had IgG and IgM levels above the normal range. This was statistically significant for IgG in women with grade 3 and for IgM in those with grade 4 endometriosis, IgG levels were significantly higher in antibody-positive women with endometriosis than in the control group. Immunoglobulin and complement component levels tended to have a positive correlation with stage of disease.

Adolescent↗

PubMed1991

Follicular development in spontaneous and stimulated cycles in women with minimal-mild endometriosis.

OBJECTIVE: To study follicle development in women with minimal-mild endometriosis. DESIGN: In women with endometriosis a spontaneous ovulatory cycle was compared with two subsequent cycles in which either clomiphene or clomiphene and FSH were given to stimulate folliculogenesis. Spontaneous cycles in women with tubal infertility provided a comparison group. SETTING: Infertility clinic, Aberdeen Maternity Hospital. SUBJECTS: 17 women with minimal-mild endometriosis and 10 women with tubal infertility. INTERVENTIONS: The women with endometriosis were treated with 150 mg clomiphene citrate from days 2 to 6 in one cycle and in a subsequent cycle with 150 mg clomiphene citrate on days 2 to 6 plus 75 iu FSH daily thereafter. MAIN OUTCOME MEASURES: Follicular size measured daily using ultrasound. Serum FSH estimated on days 5 and 7 and then daily. RESULTS: Spontaneous follicular growth in the women with endometriosis was similar to that in the women with tubal infertility. Follicular development began earlier in cycles with clomiphene/FSH and the leading follicle reached 16 mm 2 days sooner but the rate of growth was similar whether or not either regimen of stimulation was used. CONCLUSION: Follicular growth is not impaired by minimal-mild endometriosis. Infertility with this condition cannot be explained by altered follicular growth or responsiveness.

Adult↗

PubMed1997

Menstrual characteristics associated with endometriosis.

This case-controlled study investigates whether the presence of menstrual characteristics, which may increase the exposure of the peritoneal cavity to retrograde menstruation, increases the risk of developing endometriosis. The menstrual characteristics considered were 1. age at menarche of less than 12 years, 2. duration of menstrual flow greater than five days and 3. menstrual cycle lengths of < 28 days. The frequency with which these menstrual characteristics occurred in 305 women with proven endometriosis was compared with their frequency in 305 age-matched women without endometriosis. Adjusting for the confounding factors of parity, age at first childbirth and social class, the only menstrual characteristic that was significantly associated with endometriosis was menstrual cycle lengths of less than 28 days (odds ratio 1.83; 95% confidence intervals 1.60-2.55). There was insufficient evidence to conclude that the presence of menstrual characteristics which may increase the exposure of the peritoneal cavity to retrograde menstruation, increase a women's risk of developing endometriosis. The association of short menstrual cycle lengths with endometriosis may have been consequential rather than causal.

Adult↗

PubMed2000

The effect of endometriosis and its radical laparoscopic excision on quality of life indicators.

OBJECTIVE: To assess the effect of endometriosis and radical laparoscopic excision on the quality of life of women with this condition. DESIGN: A prospective study. SETTING: The Northern Endometriosis Centre at South Cleveland Hospital, Middlesbrough and St. James's University Hospital, Leeds. POPULATION: Fifty-seven consecutive patients undergoing laparoscopic excision of invasive endometriosis. METHODS: Questionnaires, both pre-operatively and four-month post-operatively, for a number of different symptoms associated with endometriosis were completed by patients. Details of fertility, previous treatments and quality of life as measured by SF12 and EuroQOL (EQ-5D) and sexual activity questionnaire, as well as linear pain scores for several symptoms, were recorded. Details of intra-operative findings was also collected. MAIN OUTCOME MEASURES: Effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, length of surgery and incidence of intra- and post-operative complications. RESULTS: Patients with endometriosis were severely ill with significant pain and impairment of quality of life and sexual activity. Four months after radical laparoscopic excision for deep endometriosis there was significant improvement in all the parameters measured including their quality of life based on EuroQOL evaluation: EQ-5D (0 x 595:0 x 729, P = 0 x 002) and EQ thermometer (68 x 9:77 x 7, P = 0 x 008); SF12 physical score (44 x 8:51 x 9, P = 0 x 015); sexual activity (habit P = 0 x 002, pleasure P = 0 x 002 and discomfort P < or = 0 x 001). Only the mental health score of SF12 failed to show any statistical improvement (47 x 1:48 x 4, P = 0 x 84). Symptomatically, there was a significant reduction in dysmenorrhoea (median 8 x 0:4 x 0, P < or = 0 x 001), pelvic pain (median 7 x 0:2 x 0, P < or = 0 x 001), dyspareunia (median 6 x 0:0 x 0, P < 0 x 001) and rectal pain scores (median 4 x 0:0 x 0, P < 0 x 001). Complications were noted, but were deemed to be acceptable for the extent of the surgery. CONCLUSIONS: This is an early analysis of the first 57 cases studied, but structured evaluation suggests that meaningful improvements in clinical symptoms and quality of life can be obtained with this approach with acceptable levels of operative morbidity. Further follow up of this series is required, but early evidence would suggest that the technique should be further evaluated as part of a randomised trial.

Endometriosis↗

PubMedDate not supplied

Carcinosarcoma arising from atypical endometriosis in a cesarean section scar.

Malignant change of endometriosis in a cesarean scar (CS) is rare. We report a case of carcinosarcoma arising from atypical endometriosis in a CS scar, which was successfully treated with complete excision of the lesion and repair of the abdominal wall defect with autologous skin-muscle flap graft. A 41-year-old woman presented with a recurrent endometriosis in a CS scar. Within 16 years it changed from benign to atypical endometriosis and finally to carcinosarcoma after three operations. Complete excision of the tumor was performed, with a big defect of abdominal wall successfully repaired by autologous pedicle skin-muscle graft. The diagnosis of carcinosarcoma arising from atypical endometriosis was confirmed histologically. The lesion recurred 6 months after the fourth operation. She died of disease 15 months after the fourth operation. This case demonstrated that long-standing recurrent scar endometriosis could undergo malignant changes and should be made aware. The primary treatment is complete surgical excision.

Abdominal Wall↗

PubMed2006

Migraine is associated with menorrhagia and endometriosis.

OBJECTIVE: To evaluate the frequency of menorrhagia and endometriosis in female migraineurs compared to age-matched women without headache. BACKGROUND: Migraine predominantly affects women of childbearing age and is often associated with the menstrual period, yet there is a paucity of data regarding the relationship of migraine and menstrual disorders. METHODS: Women diagnosed with migraine, using International Headache Society criteria and an age- and sex-matched control group, were administered a semistructured questionnaire regarding migraine and migraine-related disability, menstrual history, other bleeding history, vascular event history, and vascular risk factors. RESULTS: Fifty female migraineurs between the ages of 22 and 50 years and 52 age-matched women (mean age 37 years) were enrolled in the study. Similar proportions of women in each group reported using hormone contraceptives (30% vs. 33%, P = .77) and hormone replacement therapy (12% vs. 8%, P = .69). The proportions presently menstruating (64 % vs. 80%, P = .20) and status after hysterectomy were similar (24% vs. 14%, P = .84). Menorrhagia (defined as at least three consecutive heavy periods), both current and prior, was more commonly reported in migraineurs (63% vs. 37%, P = .009), with higher likelihood of staining clothes by menses (35% vs. 8%, P = .003), and significant impact of menses on activities of daily living (on a 10-point Likert scale) with work/school participation (P = .02), family activities (P < .0001), sleep (P = .003), life enjoyment (P = .001), mood (P = .02), and overall quality of life (P = .003). Endometriosis, which may be associated with menorrhagia, was also more commonly diagnosed in the migraineurs (30% vs. 4%, P = .001). The migraineurs more frequently described bruising (40% vs. 10%, P < .001) and rectal bleeding (18% vs. 2%, P = .017) but not more serious bleeding problems. Nonsteroidal anti-inflammatory drug (NSAID) use was more frequent in the migraine group (28% vs. 12%, P = .036), and significance for increased menorrhagia, endometriosis, menstrual interference, and bruising was maintained, even when controlling for the use of NSAIDs. With logistic regression, menorrhagia was significantly associated with migraine, adjusted odds ratio (OR) = 2.8 (95% CI 1.2 to 6.5), and with endometriosis, adjusted OR = 10.5 (95% CI 2.2 to 51.4). There were no differences in vascular events and risk factors, except for trends of increased hypertension (25% vs. 10%, P = .05), transient ischemic attack/stroke (10% vs. 2%, P = .08), and Raynaud's disease (10% vs. 2%, P = .08) in the migraineurs. CONCLUSION: Women with migraine have a higher frequency of menorrhagia, endometriosis, and associated psychosocial consequences. These findings suggest that there should be further study of factors influencing endometriosis and menstrual blood flow, such as eicosanoids and platelet function, in migraineurs.

Adult↗

PubMed1993

MAST scores, alcohol consumption, and gynecological symptoms in endometriosis patients.

Alcohol consumption (quantity, frequency, and pattern) and alcohol-related problems were determined in endometriosis patients (n = 137), patients with other gynecological disorders (n = 91), and normal control subjects (n = 98). Participants completed a self-administered questionnaire, including the Michigan Alcoholism Screening Test (MAST), questions to determine the quantity and frequency of alcohol use, and questions regarding the relationship between gynecological symptoms and alcohol intake. The percentage of endometriosis patients with MAST scores greater than five or seven was significantly greater than that of normal control subjects (p = 0.045 and p = 0.009, respectively), but did not differ from that for patients with other gynecological disorders. Endometriosis patients with high MAST scores (> or = 5) tended to consume more alcohol on a yearly basis than normal control subjects with high MAST scores (p = 0.07). Among participants who experienced gynecological symptoms and were not abstainers, 31% of endometriosis patients, 9.5% of normal control subjects, and 14.3% of patients with other gynecological disorders reported increasing their alcohol consumption when experiencing gynecological symptoms. Endometriosis patients tended to differ in this regard from normal control subjects (p = 0.058) and were significantly different from patients with other gynecological disorders (p = 0.039). The evidence suggests that the gynecological problems of endometriosis may be a major medical correlative of alcoholism in women.

Adult↗

PubMedDate not supplied

The relationship between women's symptoms of endometriosis and self-esteem.

OBJECTIVE: To determine the relationship between women's symptoms of endometriosis and self-esteem. DESIGN: Descriptive. SETTING: Private practice. PARTICIPANTS: Twenty-three mostly middle class, employed women who had been diagnosed with endometriosis and had received treatment from a physician. METHOD: The volunteer subjects completed a two-part questionnaire. One part consisted of questions on demographic characteristics, health history, menstrual history, and symptoms of endometriosis, and the other part consisted of the Rosenberg Self-Esteem Scale. MAIN OUTCOME MEASURES: The relationship between women's self-esteem and perceptions of the number, frequency, and severity of their symptoms. RESULTS: No significant correlation was found between self-esteem and the number, frequency, and severity of endometriosis symptoms. Significant correlations were found between the number/frequency of symptoms and the severity of pain and between the frequency and number of symptoms. CONCLUSION: Although endometriosis symptoms did not influence self-esteem, they interfered with women's lives. Assessment of psychosocial status and nursing interventions designed to relieve pain are important factors in assisting women with endometriosis.

Adaptation, Psychological↗

PubMed1996

Identification of rhesus macaques with spontaneous endometriosis.

Rhesus macaques (Macaca mulatta) with endometriosis were identified using reproductive histories, serum levels CA-125, pelvic ultrasonography, laparoscopy, and histopathology. All animals were evaluated from a large breeding colony and had a history of infertility and/ or spontaneous abortions. Laparoscopy and ultrasonography were performed on 40 macaques: 27 macaques from the breeding colony with elevated CA-125 levels, ten macaques from the breeding colony with normal or low serum CA-125 levels, and three macaques from another facility with previously diagnosed spontaneous endometriosis. Clinical endometriosis was diagnosed by laparoscopy in 16/37 (43%) macaques from the breeding colony and was confirmed by histologic examination in all animals biopsied. The disease was classified as minimal (40%), mild (25%), moderate (10%), or severe (25%). The most common sites of endometriosis were the serosal surface of the uterus (75%) and the posterior cul-de-sac (75%). In this study, CA-125 levels were useful in identifying animals from the breeding colony with endometriosis. The rhesus macaque provides a valuable animal model to study endometriosis and potentially to assess efficacy of therapeutic agents for this disease condition.

Animals↗

PubMed1987

Enhancement of human monocyte and peritoneal macrophage chemiluminescence activities in women with endometriosis.

Preliminary reports indicate that products of human mononuclear phagocytes may contribute to the infertility associated with endometriosis. To determine whether the generation of reactive oxygen metabolites by blood monocytes and peritoneal macrophages is altered in women with endometriosis, the present study evaluated luminol-enhanced chemiluminescence (CL) in cells at rest and following stimulation with phorbol myristate acetate (PMA) or serum-opsonized zymosan (SOZ). Peripheral venous blood and peritoneal fluid samples were collected from 60 infertile women undergoing diagnostic laparoscopy at midluteal phase and mononuclear phagocytic cell fractions were obtained by density gradient centrifugation. Whereas there was no significant difference between resting CL values in peripheral blood monocytes collected from women with and without endometriosis, PMA- and SOZ-stimulated monocyte CL was significantly greater in endometriosis patients. In contrast, there was a significant elevation in resting CL values when peritoneal macrophages from endometriosis patients were compared with macrophages obtained from patients with normal pelvic organs. It appears that chronic stimulation of macrophages in the peritoneal cavity provokes constitutive release of large quantities of reactive oxygen products in women with endometriosis. This may occur secondary to the accumulation of activated monocytes into the peritoneal cavity.

Adult↗

PubMedDate not supplied

Enhanced expression of resident leukocyte interferon gamma mRNA in endometriosis.

PROBLEM: Previous studies have shown that the endometrial epithelial/stromal cell proliferative activity of endometriosis is significantly less than that of normal endometrium and that the concentration of resident stromal leukocytes is significantly greater in ectopic than in eutopic endometrium. Other work has shown that interferon gamma (IFN gamma), secreted by resident leukocytes, inhibits endometrial cell proliferation in vitro. Accordingly, we hypothesized that the lower proliferative activity of endometriosis may be related to enhanced resident leukocyte IFN gamma production. This study was designed to assess whether resident leukocytes in endometriosis express IFN gamma mRNA and to compare this expression to that of normal endometrium. METHODS: Biopsies of ectopic endometrium (N = 16) from women in the follicular phase and normal proliferative (N = 9) and secretory (N = 8) endometria were examined for IFN gamma expression. Using monoclonal antibodies specific for CD45 (leukocyte common antigen), CD3 (a T-cell marker) and CD11c (a macrophage marker), leukocyte types were identified immunocytochemically, followed by in situ hybridization to examine expression of IFN gamma mRNA. RESULTS: Results demonstrated that (1) the overall concentration of T cells and macrophages expressing IFN gamma mRNA is significantly greater in endometriosis as compared to eutopic endometrium, and (2) the percent of each leukocyte type expressing IFN gamma mRNA is greater in endometriosis than in normal endometrium. CONCLUSIONS: These findings support a possible paracrine role for resident leukocytes in regulating cell proliferation in endometriosis.

Adult↗

PubMed1995

Differential expression of VLA beta 1 (CD29) on monocytes from patients with endometriosis.

PROBLEM: Previous studies have established that in vitro proliferation of endometrial cells is enhanced by peripheral blood monocytes (PBM) and suppressed by peritoneal macrophages (PM) from patients with endometriosis but only suppressed by PBM and PM obtained from normal subjects. The functional activity of PBM and PM is influenced by the engagement of numerous cell surface receptors with their respective physiological ligands. METHOD: In this study, PBM and PM from fertile women (Group 1), women with unexplained infertility (Group 2), and women with limited (Group 3) or severe (Group 4) endometriosis were isolated in order to analyze these cells for the expression of CD54, CD58 and HLA-DR (immunoglobulin supergene antigens) CD18 and CD29 (integrins) and CD44 (an addresin). These cell surface antigens are involved in monocyte/macrophage trafficking, activation, signal transduction and/or adhesion. RESULTS: No differences were detected in the percentage of PBM expressing CD18, CD44, CD54, CD58, or HLA-DR among the four groups of subjects. Furthermore, the density of these antigens expressed on PBM was identical in patients and control subjects. In contrast, the percentage of PBM expressing CD29 (also known as VLA beta 1) and the density of CD29 expressed per cell were significantly reduced (P < 0.01) in patients with limited endometriosis compared to controls and patients with severe disease. Interestingly, although the percentage of CD29+ PBM from women with severe endometriosis was not statistically different from the percentage of CD29+ PBM from controls, the density of CD29 expressed per cell was significantly elevated among patients with severe disease. Analysis of PM from the four subject groups revealed no differences in CD29 expression or density. However, the percentage of PM expressing CD18 was significantly decreased in patients with limited (but not severe) endometriosis. CONCLUSION: Since both CD18 and CD29 play a role in cell trafficking and/or adhesion, alterations in their expression among patients with endometriosis suggest that these integrin beta chains may play a role in the pathogenesis of the disease.

Endometriosis↗

PubMed1995

IL-1 beta, TNF-alpha, and IL-2 in peritoneal fluid and macrophage-conditioned media of women with endometriosis.

PROBLEM: The presence of various cytokines in human peritoneal fluid has been incompletely evaluated. Changes in cytokine levels may be related to the development of endometriosis, infertility, and activation of peritoneal macrophages. This study assesses levels of IL-1 beta, IL-2 and TNF- alpha in peritoneal fluid and macrophage conditioned media of women with endometriosis. METHOD: Peritoneal fluid was collected from 51 women at the time of diagnostic or operative laparoscopy for benign gynecologic disease. Peritoneal macrophages were isolated, cultured for 24 h, and the culture media collected. IL-1 beta, IL-2, and TNF- alpha levels were determined by commercial ELISA kits. RESULTS: The mean concentration of IL-1 beta and TNF- alpha was significantly higher in macrophage conditioned media of patients with endometriosis (P < 0.02). However, there were no significant changes in peritoneal fluid cytokine levels. Peritoneal macrophage concentrations were also higher in patients with endometriosis. CONCLUSION: This study supports the concept that endometriosis is associated with activation of peritoneal macrophages, and a higher concentration of these cells. This activation is reflected by the increased levels of cytokines found in macrophage conditioned media. The absence of significant changes in peritoneal fluid cytokine levels would seen to indicate that the above derangements are not responsible for the development or progression of endometriosis.

Adult↗

PubMed1996

In vitro sperm phagocytosis by human peritoneal macrophages in endometriosis-associated infertility.

PROBLEM: The mechanism of infertility in women with endometriosis remains obscure. In this context the role of peritoneal macrophage's sperm phagocytic ability in infertile women with and without endometriosis was investigated. METHOD: Analysis of peritoneal macrophage concentration and in vitro sperm phagocytosis in 10 infertile women with endometriosis and 10 infertile women without endometriosis was carried out. RESULTS: It was observed that infertile women with endometriosis are associated with higher concentration and higher sperm phagocytic activity of peritoneal macrophages than those without endometriosis. CONCLUSION: Despite the small number of women in this study, it may be concluded that the increased number of peritoneal macrophages coupled with enhanced in vitro sperm phagocytosis may disturb fertilization and thereby cause infertility.

Endometriosis↗