Retroperitoneal subpancreatic ectopic pregnancy following in vitro fertilization in a patient with previous bilateral salpingectomy: how did it get there?

An unusual case of retroperitoneal ectopic pregnancy is reported. The patient, a 34 year old nulligravida, underwent IVF/ET following bilateral salpingectomy. A small, degenerating, intrauterine gestational sac suggested failing intrauterine pregnancy. There was no intraperitoneal free fluid. On Day 41 after ET, the patient was hospitalized because of acute epigastric pains. A pseudocyst of the head of pancreas was demonstrated by CT scan. A day later, exploratory laparotomy, because of a precipitous drop in the hemoglobin, revealed a massive retroperitoneal hematoma and an embryo in the gestational sac attached to the head of pancreas and major blood vessels. The patient did well following surgery. The mechanisms of retroperitoneal embryo migration are discussed and literature is reviewed.

Apoptosis in endometrial glandular and stromal cells in women with and without endometriosis.

BACKGROUND: The aetiology of endometriosis is unknown. Ectopic dissemination of the endometrial cells gives origin to endometriotic lesions, but occurs in women with and without endometriosis. It has been suggested that increased ectopic cell survival facilitates their implantation. The objectives of this study were to evaluate endometrial apoptosis in women with endometriosis according to: (i) cyclic changes, (ii) glandular and stromal contribution, and (iii) stage of the disease. METHODS: The subjects were women undergoing diagnostic laparoscopy and endometrial biopsies for suspected endometriosis. Spontaneous apoptosis was evaluated using TdT-mediated dUTP-biotin nick end-labelling (TUNEL) assay. Apoptotic cells per 10 mm(2) (apoptotic index) in an area of 10-50 mm(2) in 5 microm endometrial tissue sections were counted and location of these cells was recorded. RESULTS: The apoptotic index in glandular epithelium was lower in endometriosis than controls (26.0 +/- 5.5 versus 51.2 +/- 9.7, P = 0.03) but not in the stroma (36.3 +/- 6.4 versus 48.4 +/- 11.3, NS). In controls, apoptosis was highest during the late secretory/menstrual and early proliferative phases and cyclic variability was apparent. In endometriosis, this cyclic variability was lost. There was a trend toward decreased apoptosis with increasing stage of the disease, but the differences lacked statistical significance. CONCLUSIONS: Spontaneous apoptosis is decreased in the endometrial glands in women with endometriosis, especially during late secretory/menstrual and early proliferative phases of the cycle. This may indicate increased viability of endometrial cells shed during menses, facilitating their ectopic survival and implantation.

Postlaparoscopic small bowel obstruction secondary to unrecognized nodular endometriosis of the terminal ileum.

Small bowel involvement by endometriosis occurs in about 0.5% of patients, but nodular endometriosis involving the entire wall of the terminal ileum is extremely rare. Endometriotic nodules protruding into the intestinal lumen may lead to chronic, partial, or acute complete small bowel obstruction and associated clinical changes. If obstruction is partial, preoperative diagnosis is difficult and seldom suspected, and no reliable diagnostic tests are available. At laparoscopic surgery, performed typically for associated pelvic endometriosis, bowel lesions may easily be overlooked, especially in women with abdominal adhesions from earlier surgery. Surgical injury, tension tears, or postoperative edema may contribute in such cases to the development of acute, complete small bowel obstruction, which may be difficult to differentiate from postoperative ileus. The patient may deteriorate rapidly and develop abdominal sepsis and multiple organ failure with high risk of mortality. Because of increased production of tumor necrosis factor-alpha by autologous monocytes, endometriosis may predispose to development of severe sepsis and septic shock. (J Am Assoc Gynecol Laparosc 8(1):161-166, 2001)

Intracytoplasmic sperm injection into zona-free human oocytes results in normal fertilization and blastocyst development.

Zona-free human oocytes are frequently encountered in in-vitro fertilization (IVF) laboratories. The oocytes escape out of the zona pellucida, following zona fracture, which can occur during oocyte retrieval or manipulation, but occasionally may be the result of increased zona fragility. Some of the zona-free oocytes are mature and morphologically healthy; nevertheless, all are typically discarded. In this report, we demonstrate that zona-free oocytes can be fertilized normally using intracytoplasmic sperm injection (ICSI) and can subsequently develop without zona to the blastocyst stage in vitro. We therefore suggest that those mature and morphologically normal zona-free oocytes may be rescued, fertilized with ICSI and then cultured to the blastocyst stage for subsequent transfer or cryopreservation.

Endometriosis: abnormal endometrium and dysfunctional immune response.

This review highlights recent studies that illuminate the role of the immune system in endometriosis. The findings are discussed in the framework of a model which proposes that endometriosis reflects an immunological selection process. Endometrial cells, which are inherently resistant to apoptosis and immune-mediated elimination, acquire the capacity to utilize the products of an activated immune system to establish ectopic foci of disease. Cyclical inflammatory/immune cell stimulation that fails to eliminate ectopic endometrial implants results in progressive immunological derangement and associated pathophysiological changes which are characteristic of the disease.

Historical prospective cohort study of the recurrence of pain after discontinuation of treatment with danazol or a gonadotropin-releasing hormone agonist.

OBJECTIVE: To determine the duration of time to the recurrence of pain attributable to endometriosis after the discontinuation of treatment with danazol or a GnRH agonist (GnRH-a) in patients who have had a satisfactory response to the treatment. DESIGN: Retrospective study. SETTING: Nine academic medical centers in three countries. PATIENT(S): Three hundred twenty-seven women with diagnosed and staged endometriosis who were treated with at least 6 months of danazol or a GnRH-a and who experienced significant pain relief with therapy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Duration of pain relief after completion of treatment as determined by a patient-initiated report of pain recurrence or increase in pain severity requiring intervention. RESULT(S): The median time to the recurrence of pain was 6.1 months for patients treated with danazol and 5.2 months for patients treated with a GnRH-a. CONCLUSION(S): Although there was a lack of uniformity in treatment effects across sites, the analyses have taken into account major covariant effects. The time to the recurrence of endometriosis-associated pain after danazol treatment was slightly longer than that after GnRH-a treatment.

Spontaneous apoptosis of endometrial tissue is impaired in women with endometriosis.

OBJECTIVE: To evaluate spontaneous apoptosis in single-cell suspensions of eutopic and ectopic endometrium from women with endometriosis and in eutopic endometrium from fertile controls without endometriosis. DESIGN: Paired specimens of eutopic and ectopic endometrial tissue from patients with endometriosis and eutopic endometrium from controls were assessed for spontaneous apoptosis. SETTING: Institute for the Study and Treatment of Endometriosis and university-based research laboratories. PATIENT(S): Fertile controls (n = 10) and women with untreated endometriosis (n = 16). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Spontaneous apoptosis assessed with an ELISA-based cell death detection kit. RESULT(S): Spontaneous apoptosis (monitored by absorbance) of eutopic endometrium from patients with endometriosis and fertile controls was 0.63 +/- 0.1 and 1.43 +/- 0.11, respectively. Among patients with endometriosis, spontaneous apoptosis of ectopic endometrium was 0.26 +/- 0.06. Decreased apoptosis of ectopic versus eutopic endometrium was observed independent of cycle phase. CONCLUSION(S): The susceptibility of endometrial tissue to spontaneous apoptosis is significantly lower in women with endometriosis than in fertile controls. We suggest that decreased susceptibility of endometrial tissue to apoptosis contributes to the etiology or pathogenesis of endometriosis.

Cytolysis of eutopic and ectopic endometrial cells by peripheral blood monocytes and peritoneal macrophages in women with endometriosis.

OBJECTIVE: To compare the ability of peripheral blood monocytes (PBM) and peritoneal macrophages (PM) to mediate the in vitro cytolysis of endometrial cells from eutopic and ectopic endometrium in women with endometriosis. DESIGN: Prospective study of immune function. SETTING: Institute for the Study and Treatment of Endometriosis and university-based research laboratories. PATIENT(S): Twenty-four women with endometriosis (15 in stage I/II, 9 in stage III/IV) and 4 patients treated with GnRH agonists. INTERVENTION(S): Peritoneal fluid and peripheral blood were sampled and eutopic and ectopic endometrium were biopsied during diagnostic laparoscopy. MAIN OUTCOME MEASURE(S): Lysis of autologous endometrial cells. RESULT(S): Peripheral blood monocytes were significantly more cytolytic than peritoneal macrophages against autologous uterine endometrial cells. However, PBM and PM displayed a similar degree of cytolysis against a hepatoma cell line. Ectopic endometrial cells were significantly more resistant to cytolysis by autologous PBMC than were matched eutopic endometrial cells, and were completely resistant to cytolysis by autologous PM. CONCLUSION(S): The reduced capacity of PM from women with endometriosis to mediate the destruction of endometrial cells coupled with the increased resistance of ectopic endometrial cells to macrophage-mediated cytolysis may facilitate the survival of these cells within the peritoneal cavity of women with endometriosis.

Decreased apoptosis and sensitivity to macrophage mediated cytolysis of endometrial cells in endometriosis.

Ectopic dissemination of endometrial cells and their subsequent implantation are the mechanisms involved in the development of endometriosis. While the process of dissemination appears to be a phenomenon common to all women, it is unknown what facilitates or prevents ectopic implantation of misplaced endometrial cells. Prior studies by our group and others suggest that cell-mediated immunity in patients with endometriosis is decreased. The present studies evaluated (i) peripheral blood monocyte (PBM) and peritoneal macrophage (PM) mediated cytolysis of autologous eutopic and ectopic endometrial cells and (ii) programmed cell death (apoptosis) in the eutopic and ectopic endometrium. PBM-mediated cytolysis was (mean+/-SD) 23.1+/-13% for the eutopic and 7.8+/-% for the ectopic endometrium (P < 0.004), while the corresponding percentages for PM-mediated cytolysis were 5.4+/-7 and 0.3+/-1 respectively (P < 0.04). This indicates that PBM are much more effective than PM in inducing cytolysis of both eutopic and ectopic endometrium and that ectopic endometrial cells are significantly more resistant to both PBM- and PM-mediated cytolysis. The apoptosis was significantly decreased in the eutopic endometrium of women with endometriosis as compared to fertile controls (0.375+/-0.17 versus 1.57+/-0.3, P < 0.0001). Furthermore, in matched samples apoptosis was significantly lower in the ectopic (0.149+/-0.075) than eutopic (0.375+/-0.17) endometrium (P < 0.001). We conclude from these studies that the decrease in the capacity of monocytes to mediate cytolysis of the misplaced endometrial cells in the peritoneal locations and an increased resistance of these cells to apoptosis are fundamental to the aetiology and/or pathophysiology of endometriosis.

Embryo implantation during menstruation in the absence of adequate estradiol and progesterone support, with subsequent normal response to ovulation induction and superfetation.

OBJECTIVE: To report an unusual case of embryo implantation and superfetation. DESIGN: Retrospective case analysis. SETTING: Oak Brook Fertility Center. PATIENT(S): A 41-year-old woman underwent two consecutive ovarian stimulation cycles interrupted by a normal menstrual period. Ovulation and implantation occurred during both cycles. The first embryo conceived developed normally until term; the second failed to develop. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Retrospective analysis of stored blood samples for serum E2, P, and beta-hCG levels. RESULT(S): Rising beta-hCG levels during menstruation indicated normal embryonic implantation in the absence of adequate E2 and P support. During subsequent ovarian stimulation, there was a normal follicular and E2 response and normal ovulation in spite of the ongoing pregnancy. The second embryo, conceived during the second cycle of stimulation, implanted but failed to develop. CONCLUSION(S): This unusual case indicates that E2, P, and endometrial thickness requirements for successful implantation may not always be as critical as postulated previously. The absence of a decidual response might have facilitated superfetation.

Albumin gradients do not enrich Y-bearing human spermatozoa.

The aim of this study was to evaluate objectively whether or not discontinuous albumin gradients enrich the proportion of Y-bearing human sperm. A blinded, collaborative trial design was employed whereby a licensed centre prepared the sperm fractions using licensed procedures, coded the sperm slides and then sent them to an independent laboratory for determination of the X:Y ratio in each sperm fraction using X and Y chromosome-specific probes and double label fluorescence in-situ hybridization (FISH). The identification codes and FISH results were collated by an independent third observer. Two albumin gradient methods which are currently used by licensed centres for male sex pre-selection, protocol 3 and modified protocol 3, were tested. Essentially the same results were obtained for the two methods. Highly motile sperm fractions were recovered from the albumin gradients, and the recoveries of motile spermatozoa (1.3-8.5%) were within the optimal range reported to produce maximal enrichment of Y-bearing spermatozoa. FISH analysis, however, revealed no enrichment for Y-bearing spermatozoa with either method, and the overall X:Y ratios were not significantly different from 1.0. Some samples showed marginal enrichment of Y-bearing spermaotozoa, whereas others showed marginal enrichment of X-bearing spermaotozoa. In conclusion, this collaborative study has demonstrated that the protocol 3 and modified protocol 3 albumin gradient procedures do not enrich Y-bearing spermatozoa. The clinical use of albumin gradients for male sex preselection should be reconsidered in the light of this and other evidence.

Subcutaneous estradiol pellets for endometrial preparation in donor oocyte recipients with a poor endometrial response.

PURPOSE: The purpose of this study was to evaluate the clinical effectiveness of subcutaneous estradiol pellets in donor oocyte recipients with an inadequate endometrial response. METHODS: The subjects were 13 women with ovarian failure and a maximal endometrial thickness < 10 mm on standard estrogen regimens, as demonstrated during mock and/or prior oocyte donation cycles. They underwent pellet implantation (100-250 mg of estradiol) 6-13 weeks before oocyte donation. RESULTS: maximal (mean +/- SD) endometrial thickness was 8.7 +/- 1.5 mm on standard regimens, in contrast to 11.7 +/- 1.8 mm on pellets, while estradiol levels were 674 +/- 844 and 815 +/- 706 pg/ml, respectively. The estradiol:estrone ratio on pellets was > 1. There was 1 pregnancy with early loss during 10 cycles on other estrogen regimens and 12 pregnancies during 19 cycles on pellets. The pregnancy and implantation rates were, respectively, 63 and 27% on pellets and 41 and 14% on standard regimens in historical controls. CONCLUSIONS: We conclude that estradiol pellets after a single administration provide constant estradiol levels extending into the first trimester of pregnancy, a physiologic estradiol:estrone ratio, and a better endometrial response than standard estrogen regimens. Implantation and pregnancy rates are higher. This approach may be especially suitable for recipients with a poor endometrial response.

Changing trends in the diagnosis of endometriosis: a comparative study of women with pelvic endometriosis presenting with chronic pelvic pain or infertility.

OBJECTIVE: To compare demographic, epidemiologic, and medical data and to evaluate diagnostic trends in women with endometriosis and chronic pelvic pain symptoms or endometriosis and infertility. DESIGN: Retrospective analysis. SETTING: Institute for the Study and Treatment of Endometriosis. PATIENT(S): Six hundred ninety-three consecutive patients with endometriosis and chronic pelvic pain (n = 357) or endometriosis and infertility (n = 336). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Demographic and epidemiologic parameters, diagnostic trends. RESULT(S): Women with pelvic symptoms were younger, had less formal education, more frequent family history, and higher frequency and intensity of pelvic complaints. Mean ages at first symptom and diagnosis were lower in the pain group, but stage of endometriosis at first diagnosis was more advanced. The mean "diagnostic delay" was longer in the pelvic pain than in the infertile group (6.35 versus 3.13 years), but it decreased during three consecutive 5-year intervals in both groups, and there was also a gradual decrease in the frequency of advanced endometriosis at the time of first diagnosis. CONCLUSION(S): Demographic and epidemiologic parameters in women with endometriosis differ, depending whether chronic pelvic pain or infertility are the presenting symptoms. In the pain group, diagnostic delay is longer and endometriosis at diagnostic laparoscopy more advanced, indicating progressiveness of the disease. During the last 15 years, diagnostic delay steadily decreased and the frequency of advanced endometriosis at first diagnosis declined.

Excretion of urinary N-telopeptides reflects changes in bone turnover during ovarian suppression and indicates individually variable estradiol threshold for bone loss.

OBJECTIVE: To evaluate the effectiveness of N-telopeptides and E2 in monitoring bone turnover during GnRH agonist- (GnRH-a) or danazol-induced hypoestrogenism. DESIGN: Comparative, nonrandomized prospective study. SETTING: Institute for the Study and Treatment of Endometriosis. PATIENT(S): Premenopausal women undergoing ovarian suppression with GnRH-a (n = 16) or danazol (n = 9). INTERVENTION(S): Serum and urine samples were collected and bone mineral density was measured before, during, and after treatment. MAIN OUTCOME MEASURE(S): N-telopeptide excretion, serum E2, and bone mineral density at L1 to L4 and femoral neck. RESULT(S): During treatment in the GnRH-a group, mean E2 levels were 53% below and N-telopeptides were 38% above the mean baseline. At 1 month post-treatment, L1 to L4 bone mineral density decreased by 3.85%. In the danazol group, E2, N-telopeptides and L1 to L4 bone mineral density changed nonsignificantly in the opposite direction with the mean 1.25% increase in L1 to L4 at 1 month post-treatment. In combined groups, L1 to L4 bone mineral density better correlated with other measures than femoral neck bone mineral density. N-telopeptide excretion was more predictive of L1 to L4 change, with correlation the highest between N-telopeptides at month 4 and bone mineral density at month 1 afterward, while E2 appeared more predictive of the less reliable femoral neck bone mineral density. Individual exceptions to the model of an E2 threshold for bone loss were observed. Also noted were high correlation between on-therapy levels of E2 and N-telopeptides, as well as the presence of a 1-month time lag between E2 and N-telopeptide changes. CONCLUSION(S): Bone density decreases during GnRH-a and may slightly increase during danazol treatment. However, E2 threshold for bone loss varies individually. N-telopeptides predict changes in bone mineral density at L1 to L4 better than E2.

Decrease in the size of ovarian endometriomas during ovarian suppression in stage IV endometriosis. Role of preoperative medical treatment.

OBJECTIVE: To evaluate the effect of hormonal suppression on the size of ovarian endometriomas and to develop a predictive model for changes in the size of these lesions. STUDY DESIGN: The study consisted of 80 women of reproductive age with the diagnosis of stage IV pelvic endometriosis, according to the revised American Fertility Society (rAFS) classification, and included 48 women with endometriomas > or = 3 cm. After the initial laparoscopic and sonographic evaluation, ovarian suppression was achieved with either danazol or a gonadotropin-releasing hormone agonist (GnRH-a) for six months. In all patients, pretreatment and posttreatment pelvic sonograms were performed, and at the end of treatment residual disease was evaluated and resected by laparotomy or laparoscopy. Seven of 80 women with endometriomas > or = 3 cm had serial sonograms during the course of therapy. Serial pelvic sonograms in this subgroup were used to develop a statistical model for predicting the size of endometriomas after treatment. The model was then tested in another subgroup of 41 women with endometriomas > or = 3 cm. RESULTS: At the end of treatment, there was a significant decrease in the r-AFS score in both the danazol and GnRH-a groups. Medical treatment facilitated surgical resection of residual disease and preservation of ovarian tissue. There was no difference in this respect between danazol and GnRH-a. Endometriomas decreased by 51% in both treatment groups. The predictive model, when tested on 41 patients, underestimated the actual change by 11%, but the difference was within the 95% confidence limits. CONCLUSION: This study documented, for the first time, that ovarian endometriomas decrease in size during hormonal suppression. Both danazol and GnRH-a were equally effective.

Basal and stimulated secretion of cytokines by peritoneal macrophages in women with endometriosis.

OBJECTIVE: To evaluate basal (constitutive) and stimulated synthesis of tumor necrosis factor alpha (TNF alpha), interleukin (IL)-8, IL-10 by peritoneal macrophages (PM) in women with endometriosis. DESIGN: Peritoneal macrophages were cultured in the presence or absence of lipopolysaccharide (LPS) for 24 hours. Peritoneal fluids (PF) and PM supernatants were assayed for cytokines using ELISA. SETTING: Institute for the Study and Treatment of Endometriosis and university-based research laboratories. SUBJECTS: Fertile controls undergoing tubal ligation (n = 8) and women with endometriosis (n = 17). INTERVENTION: Peritoneal fluid samples were obtained at the time of diagnostic laparoscopy (endometriosis group) or laparoscopy for tubal ligation; both were performed in the midluteal phase of the cycle. RESULTS: Both basal and LPS stimulated production of TNF alpha, IL-8, and IL-10 by the PM were elevated significantly in women with endometriosis as compared with the fertile controls. CONCLUSIONS: This study demonstrated that cytokines TNF alpha, IL-8, and IL-10 are synthesized at greater than normal levels by basal and stimulated PM from women with endometriosis. The levels of TNF alpha and IL-8 correlated with the levels in the PF, suggesting that PM are the principal source of these cytokines in the PF.

Ovarian remnant syndrome after laparoscopic hysterectomy and bilateral salpingo-oophorectomy for severe pelvic endometriosis.

Ovarian remnant syndrome is a rare complication of total abdominal hysterectomy and bilateral salpingo-oophorectomy (BSO). Ovarian enlargement and dense periovarian adhesions are the predisposing factors. Recurrent ovarian remnant syndrome was associated with recurrence of symptomatic endometriosis in a woman who underwent laparoscopic supracervical hysterectomy and BSO for severe endometriosis and extensive pelvic adhesions. After primary surgery she required five additional procedures for complete resection of all ovarian remnants. Definitive surgery for advanced endometriosis with extensive periovarian adhesions may be complicated by ovarian remnant syndrome and reactivation of the disease. Careful retroperitoneal resection of all ovarian tissue is of paramount importance in preventing the syndrome. This, however, may be a limitation of laparoscopic surgery. The choice between laparoscopy and laparotomy in such cases should be individualized and based on the degree of surgical difficulty and the surgeon's level of experience.

Urinary N-telopeptides to monitor bone resorption while on GnRH agonist therapy.

OBJECTIVES: To assess the utility of urinary cross-linked N-telopeptides in monitoring bone resorption and predicting bone loss during GnRH agonist administration. METHODS: Ninety patients who were prescribed GnRH agonist therapy for 3-6 months for treatment of endometriosis, leiomyomas or other gynecologic disorders participated in this prospective multicenter study. N-telopeptides, serum estradiol (E2), and bone mineral density were monitored before, during and up to 3 months after the course of GnRH agonist therapy. RESULTS: N-telopeptide levels increased significantly throughout GnRH agonist therapy and returned to baseline levels by 3 months after treatment was completed. A significant negative correlation was seen between N-telopeptide and E2 measurements after 3 months (r=-0.23, P<.05), 4 months (r=-0.32, P < .05), and 5 months (r=-0.41, P<.005) of GnRH agonist therapy. The percent change in bone mineral density at L1-L4 at 6 months of GnRH agonist treatment correlated inversely with the percent change in N-telopeptides from baseline to 2,3,4, and 5 months of treatment; the percent change of bone mineral density at the femoral neck at 6 months correlated inversely with the percent change of N-telopeptides from baseline to month 4. CONCLUSIONS: Urinary N-telopeptide determinations provide a quantitative measure of bone resorption, due to GnRH agonist-induced hypoestrogenism. Increases in resorption as measured by N-telopeptides parallel decreases in in E2 levels. Increases in N-telopeptides on GnRH agonist therapy may provide a tool to predict decreases in bone mineral density.

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.