{"paper_id":"1a86bbe3-8cd9-4590-8d68-f7d03638682e","body_text":"Periódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n251 \n \n \nPERIÓDICO TCHÊ QUÍMICA \nARTIGO ORIGINAL \nDETERMINAÇÃO DE INDICADORES DE ESTADO DE CITOCINA E FATORES DE \nANGIOGÊNESE EM PACIENTES COM ENDOMETRIOSE GENITAL EXTERNA E \nDEFICIÊNCIA DE VITAMINA D \n \nDETERMINATION OF CYTOKINE STATUS INDICATORS AND ANGIOGENESIS \nFACTORS IN PATIENTS WITH EXTERNAL GENITAL ENDOMETRIOSIS AND VITAMIN D \nDEFICIENCY \n \nОПРЕДЕЛЕНИЕ ПОКАЗАТЕЛЕЙ ЦИТОКИНОВОГО СТАТУСА И ФАКТОРОВ \nАНГИОГЕНЕЗА У ПАЦИЕНТОК С НАРУЖНЫМ ГЕНИТАЛЬНЫМ ЭНДОМЕТРИОЗОМ И \nДЕФИЦИТОМ ВИТАМИНА D \n \nAKHMEDOVA Saida R.1 *, OMAROV Nabi S-M.2; \n \n1,2 Dagestan State Medical University, Department of Obstetrics and Gynecology; \n \n* Correspondence author \ne-mail: saida.ahmedova2017@yandex.ru \n \nReceived 12 June 2019; received in revised form 30 December 2019; accepted 29 January 2020 \n \n \nRESUMO \n \nO estudo foi realizado para encontrar uma associação entre alguns indicadores de status de citocinas,  \nnível de fatores de crescimento endotelial vascular e vitamina D, em mulheres com infertilidade e endometrios e \ngenital externa (EGE), a fim de aumentar a efetividade do tratamento dessa patologia. O baixo nível de \nvitamina D na dinâmica foi determinado em 240 pacientes com idades entre 25 e 35 anos com EGE planejando  \na gravidez, determinando o nível de 25 (OH) D no soro sanguíneo pelo método quimioluminescente. O status \nde interleucina (IL -1β, IL -6, IL -4), TNF -α, VE GF-R1 no soro sanguíneo foi determinado usando imunoensaio  \nenzimático múltiplo. Os resultados dos estudos revelaram um nível aumentado de IL -6, IL -1β e TNF -α em  \ngrupos com baixo teor de vitamina D. Na vitamina D normal, foram registrados níveis significati vamente mais  \nbaixos de fator de crescimento endotelial vascular (VEGF -R1) no soro sanguíneo. As taxas de gravidez foram  \nmaiores nos grupos com níveis normais de 25 (OH) D no soro sanguíneo. O nível sérico médio de VEGF-R1 \nem mulheres grávidas que engravidaram sozinhas foi 1,3-1,5 vezes menor. \n \nPalavras-chave: endometriose genital externa, citocinas, VEGF, vitamina D. \n \nABSTRACT \n \nThe study was performed to find an association between some cytokine status indicators, level of  \nvascular endothelial growth factors, and vitamin D in women with infertility and external genital endometriosis  \n(EGE) in order to increase the effectiveness of  treatment of this pathology. The low vitamin D status in the  \ndynamics was determined in 240 patients aged 25 to 35 years with EGE planning pregnancy by determining the  \nlevel of 25 (OH) D in the blood serum using the chemiluminescent method. Interleukin st atus (IL-1β, IL-6, IL-4), \nTNF-α, VEGF -R1 in blood serum were determined using enzyme -multiple immunoassay. The results of the  \nstudies revealed an increased level of IL -6, IL-1β, and TNF -α in groups with low vitamin D content. In normal  \nvitamin D significan tly lower levels of vascular endothelial growth factor (VEGF -R1) in the blood serum were  \nregistered. Pregnancy rates were higher in groups with normal 25 (OH) D levels in the blood serum. The mean  \nserum VEGF-R1 level in pregnant women who became pregnant on their own was 1.3-1.5 times lower. \n \nKeywords: external genital endometriosis, cytokines, VEGF, vitamin D. \n \nАННОТАЦИЯ \n \nИсследованы цитокиновые показатели (IL -1β, IL -4, IL -6, ФНО -α) и VEGF -R1 у 240 пациенток с  \nнаружным г енитальным эндометриозом (НГЭ), проживающих в Республике Дагестан и планирующих  \nбеременность, с выявленным дефицитом витамина D. В результате проведенных исследований \nустановлено повышение уровня IL-6, IL-1β и ФНО-α в группах с низким содержанием витамина D. Низкие \nпоказатели фактора роста эндотелия сосудов (VEGF) в сыворотке крови достоверно коррелировали с \n DOI :  10 . 52571 / PTQ . v 17 . n 34 . 2020 . 268 _ P 34 _ pgs _ 251 _ 259 . pdf\n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n252 \n \nчастотой наступления беременности по группам. \n \nКлючевые слова: наружный генитальный эндометриоз, цитокины, фактор роста эндотелия \nсосудов, витамин D. \n \n \n1. INTRODUCTION \n \nEndometriosis is a multifactorial pathology \nthat occurs in 7 -17% of women, leading in 30 - \n50% of cases to impaired reproductive function  \n(Adamyan and Aznaurova, 2015; Yarmolinskaya  \nand Ailamazyan, 2017; Giudice, 2010). Its \npathogenesis results in the disturbance of steroid  \nhormones, the immune imbalance caused by \ninflammation and / or infection, increased the \nperitoneal activity of vascular growth factors \n(Adamyan and Aznaurova, 2015; Demir et al., \n2010; Huang et al., 2014; Laschke et al., 2011; \nOrazov, 2015; Radzinskiy et al., 2016). The anti - \ninflammatory, antiproliferative and \nimmunomodulatory vitamin D effects are known,  \nthus allowing to consider it as an effective \ntargeted endometriosis therapy (RAoE, 2015; \nAlmassinokiani et al., 2016; Ciavattini et al., \n2017; Lerchbaum and Rabe, 2014; Pike and \nMeyer, 2012). There is evidence that the \nexpression of a large number of genes encoding  \nproteins involved in proliferation, differentiation, \nand apoptosis are regulated by vitamin D \n(Denisova and Yarmolinskaya, 2017; Gysemans  \net al., 2014; Irani et al., 2015; Merhi et al., 2014). \nStudies proving vitamin D effect on the immune  \nsystem (Delvin et al., 2014; Gysemans et al., \n2014; Irani et al., 2015; Orazov, 2015) suggest  \nthat correction of its deficiency positively affects  \nthe fertility of patients with external genital \nendometriosis (EGE) (Paffoni et al., 2014). \nObjective: to assess the association of \ncytokine status, the level of angioneogenesis \nfactors, and vitamin D status in women with \ninfertility and EGE. An analysis of the association  \nbetween immunological parameters in infertility \non the background of endometriosis and vitamin \nD status will clarify further the understanding of  \nthe pathogenesis of the disease, predict and \nrealize its rational prevention and treatment. \n \n2. MATERIALS AND METHODS \n \nA prospective comparative analysis of the  \nresults of 240 patients of reproductive age \nmanagement, who had a histologically confirmed  \ndiagnosis of external genital endometriosis and  \ninfertility depending on the treatment methods \nfrom 2016 to 2019, was made. The study was  \napproved by the ethics committee protocol \nnumber has no conflict of interest and was \nperformed without financial support from \npharmaceutical companies. \nAll patients were examined and treated in  \nthe departments of operative gynecology No. 1  \nand No. 2 of the Republic Clinical Hospital in \nMakhachkala, and in the Family Planning and \nReproduction Room. All patie nts, depending on  \nmanagement tactics, were divided into groups of \n60 persons: group 1 - after surgical treatment \n(ST), but without correction of vitamin D \ndeficiency, group 2 - ST + vitamin  D, 3- group - \nST + dienogest (without correction of vitamin D  \ndeficiency), 4 - ST + dienogest + vitamin D. The  \nmean age of patients from the 1st group was 30.7 \n± 0.5 years and did not statistically differ from the  \nmean age of patients from the 2nd group (31.4 ± \n1.1 years), 3rd group (28.4 ± 1.2 years) and 4th  \ngroup (30.1 ± 0.7 years). Inclusion criteria were  \nage 25 -35 years, 25 (OH) D blood serum level  \nbelow 30 ng/ml, surgical removal of foci of \nendometriosis, the patient’s desire to become \npregnant, written consent of women to participate \nin the study. Exclusion criteria were pregnancy,  \nvaricose veins, systemic autoimmune diseases,  \nmental disorders, malignant diseases, \nconcomitant genital and endocrine pathologies, \nmale infertility factors. \nLow vitamin D status in dynamics was \nrevealed by determining 25 (OH) D level in blood  \nserum 3 days after taking vitamin D preparations  \nby chemiluminescent method using kits and \ncalibrators from Roche Diagnostics (Germany) for \nArchitect 2000 analyzer (USA) according to the  \ninternational standardization program for the \ndetermination of vitamin D - DEQAS. Vitamin D  \ndeficiency was determined as 25 (OH) D blood  \nserum level less than 20 ng / ml, vitamin D \ndeficiency was revealed at 25 (OH) D> 21 <29 ng \n/ ml blood serum concentration, normal vitamin D  \nlevel at 25 (OH) D blood serum concentration \nmore than 30 ng / ml. Severe vitamin D \ndeficiency is classified as a condition in which the  \nconcentration of 25-hydroxycalciferol in the blood  \nis less than 10 ng / ml (RAoE, 2015). It should be  \nnoted that none of the patients included in the  \nstudy had a normal vitamin D concentration D in  \nthe body during the initial examination. The \ninterleukin   status   (IL-1β,   IL-6,   IL-4),   TNF-α, \n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n253 \n \nVEGF-R1 in the blood serum of the examined \nwomen was determined using enzyme -multiplied \nimmunoassay using the appropriate standard \nreagents (Cloud-Clone Corp., China; R&D \nSystems Inc., USA). \nCholecalciferol dosage of was determined  \naccording to the degree of vitamin D deficiency  \ndetected during the initial examination (1300 U  \nper 10 ng / ml), and the course dose according to  \nthe recommendations (RAoE, 2015) was 200 \nthousand MU for therapy of insufficiency and 400  \nthousand MU - vitamin D deficiency. Therapy with \ndienogest in a dose of 2 mg once a day was \ncarried out continuously for 3-6 months \n(Adamyan and Aznaurova, 2015). \nStatistical data processing was performed  \nby Statistica v.6.0 program using Student's \ncriterion for groups with parametric values, and  \nSpearman's method for rank, nonparametric \nvalues for assessing the correlation. The results \nof the study are presented as mean ± standard  \ndeviation (M ± SD). Considering that the number  \nof compared groups is four, a critical significance  \nlevel was p<0.0085. \n \n3. RESULTS AND DISCUSSION \n \nVitamin D concentration level in the body \nduring the initial examination in the 1st group was \n18.2 ± 0.4 [6.7; 27.3] ng / ml, in the 2nd group - \n17.6 ± 0.6 [5.2; 27.9] ng / ml, in the 3rd group - \n16.1 ± 0.8 [4.6; 25.8] ng / ml and in the 4th group \n17.01 ± 0.8 [5.1; 27.3] ng / ml. \nMoreover, the low vitamin D status was  \nfound with equal frequency and severity in \nseasonality and region of permanent residence of \nthe examined patients. Besides, there was no \ndependence on the vitamin D level on age and  \nsocial conditions. \nIn this study, obese women were not \nincluded. However, overweight patients (BMI 25- \n29.9 kg / m2) with almost the same frequency as  \nnormal growth and weight indicators were \nobserved. It should be noted that there were no  \npatients with insufficient body weight (BMI  <18.5 \nkg / m2). \nThe duration of infertility averaged 6.4 ± \n2.8 years in the 1st group, 5.8 ± 3.1 years in the  \n2nd group, 6.1 ± 2.4 in the 3rd group and 6.5 ± \n3.7 years in the 4th group with fluctuations from 2  \nto 16 years in groups. Moreover, in the examined  \ngroups, primary infertility significantly prevailed: in \nthe 1st group - in 81.7% of cases, in the 2nd \ngroup - in 86.7%, in the 3rd group - in 80.0% and \nin the 4th - in 83.3% (р˂0.0085). The duration of  \nprimary infertility averaged 6.9 ± 1.2 years in the  \n1st group, 6.3 ± 0.5 years in the 2nd group, 6.7 ± \n0.7 years in the 3rd group and 6, 9 ± 0.8 years in  \nthe 4th group (р˂0.0085), and the secondary - \n3.7 ± 0.8 years in the 1st group, 4.0 ± 0.3 years in \nthe 2nd group, 3.2 ± 0.4 in the 3rd group and 3.8 \n± 0.7 years in the 4th group (р˂0.0085). \nDuring surgery, unilateral salpingo- \novariolysis was performed in 33.3% of cases in  \nthe 1st group, in 48.3% in the 2nd group, in \n51.7% in the 3rd group and in 38.3% in the 4th  \ngroup, (p˃0.05); in 20.0% of patients in the 1st  \ngroup, in 18.3% in the 2nd group, in 16.7% in the  \n3rd group and in 33.3% in 4 group 2 - bilateral \nsalpingo-ovariolysis was made (p ˂ 0.05). When  \novarian cysts were detected, cystectomy within \nhealthy tissues was performed in 100% of cases  \nusing bipolar energy. Left -sided cystectomy was  \nperformed in 13.3-26.7% of patients in the \ngroups, right-sided - in 21.7-31.7%, respectively. \nBilateral cystectomy was performed in 8.3 -18.3% \nof patients, respectively. \nAnalysis of the ratio of different color \nheterotopies revealed that violet and red \ndominated in the frequency of occurrence and \nsize in all groups. Most often, they were located \nin the Douglas space, much less often (in 6.7 - \n11.7% of cases in groups (p˂0.05)) in the area of  \nthe vesicoureteral fold, and (in 5.0 -8.3% of cases \nin groups (р˂0.05)) were dispersed along the \nperitoneum of the pelvis. \nTherapy of low vitamin D status was \neffective, and it was possible to reach the level of \n30 ng / ml, which is characterized as normal, \nwithin 4-8 weeks. Subsequently, maintenance \ntherapy was carried out. \nA 3 months after colecalciferol \nappointment in order to restore vitamin D status,  \nindicators were compared. Blood serum content \nof 25 (OH) D was 17.3 ± 0.7 [6.9; 24.8] ng / ml in \nthe 1st group, 38.6 ± 0.7 [32.7; 57.7] ng / ml in \nthe 2nd, 17.2 ± 0.7 [5.4; 24.8] ng / ml in the 3rd \ngroup and 35.6 ± 0.5 [31.9; 61.9] ng / ml in the \n4th (p˂0.0085). Moreover, in the 2nd group, 25 - \nhydroxyvitamin D level over 50.0 ng / ml was \nobserved in 41.7% of the examined, and in the \n4th group - in 38.3% (р˂0.0085). The patients did  \nnot follow any strict or special diets. \nOne month after the surgical treatment, no \ncomplaints of pain were in the 2nd and 4th \ngroups of patients. In the first and third groups,  \nwhere no correction of vitamin D deficiency was  \nperformed, several patients complaints of pain in \n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n254 \n \nthe absence and during menstruation remained,  \nbut their intensity decreased significantly. Three  \nmonths after laparoscopy, the pain syndrome \nrecurred in 5 patients in the 1st group, in 3 \npatients in the 2nd and third groups, and in 2 \nwomen in the 4th group. After 6 months, the \nrecurrence of pain syndrome was in frequency \nquite different in the groups. Thus, in groups that  \ndid not receive dienogest, the recurrence rate of  \npain was 1.6 times higher in the group without  \nvitamin D deficiency correction. In groups (in the  \n3rd and 4th), where the hormonal treatment was  \nused in complex therapy, the frequency of pain  \nwas 2.2 times more rear comparing the 3rd group  \nwith the 1st one, 1.7 times when comparing the  \n4th group with the 2nd group, and 2.7 times when \ncomparing the 4th groups with the 1st group \n(р˂0.0085). After a year of observation, the \nmaximum number of patients with pain in the 1st  \ngroup increased (by 15.0 ± 7.8% compared with \n6 months), in the 2nd group - by 10.0 ± 1.7%, in  \nthe 3rd group - by 6.7 ± 1.8% and in the 4th \ngroup - by 5.0 ± 0.7% (p˂0.0085). As a result, the \nbest indicators in pain relief were noted in the 4th  \ngroup, which received combined therapy with \ndienogest on the background of a normal vitamin  \nD level in the body. \nIn this group of patients, complaints of \npain a year after surgical treatment were 2.8 \ntimes less than in the 1st group, 1.8 times less  \nthan in the 2nd group, and 1.3 times less than in  \nthe 3rd group. The intensity of pelvic pain, \nestimated by VAS in women with pain syndrome,  \ncorresponded to an average of 3.9 ± 0.7 points in  \nthe 1st group, 3.1 ± 0.3 points in the 2nd, 3.5 ± 0.  \n6 points in the 3rd group and 2.8 ± 0.4 points in  \nthe 4th group and was 1.3 times weaker in \ngroups with normal vitamin D levels. Thus, the  \ncorrection of vitamin D status positively affects \npain syndrome treatment, as well as dienogest  \nappointment in the postoperative period, \nhowever, the effectiveness of complex interaction  \nis evident. \nComplaints of spotting before and after \nmenstruation disappeared in all patients after \nsurgical treatment, but 12 months later these \nsymptoms recurred in 25.0% of women of the 1st \ngroup, 13.3% of women of the 2nd group, 11.7%  \nof patients of the 3 group and 6.7% of the 4th  \ngroup (p˂0.0085). \nOne month after the treatment and \ndiagnostic laparoscopy, menstrual irregularities \nwere observed in 3 patients in the 1st group and \n2 in the 2nd group. After 3 months, the frequency  \nof complaints of menstrual dysfunction in these  \ngroups increased to 8.3% in the 1st group and \nremained at the same level of 3.3% in the 2nd  \ngroup (p = 0.04). After complex therapy, during 6  \nmonths this complication occurred in all patients - \nin 10.0% of cases in the 1st group, in 6.7% in the  \nsecond group, in 3.3% in the 3rd group and in 1,  \n7% in the 4th group (р˂0.0085). \nThe year of observation yielded the \nfollowing results - vitamin D administration \nallowed to reduce the frequency of menstrual \ndysfunction by 1.6 times in cases where no \nhormone therapy was carried out, and by 1.7 \ntimes when the restoration and monitoring of \nvitamin D status was accompanied by dienogest  \nintake of. A low vitamin D level and lack of \nhormonal correction resulted in this indicator \ndecrease by 4 times when comparing the 1st and  \n4th groups. \nAfter therapeutic measures aimed at \nrestoring an adequate vitamin D level, some \nindicators of cytokine status were performed, \nwhich showed that IL-6, IL-1β and TNF-α \nconcentration in the groups with a normal vitamin  \nD level was lower compared with group 1 and 3,  \nwhere vitamin D status was not corrected, their \nhigher level was registered in the group with only  \nsurgical treatment. The level of pro -inflammatory \nIL-4 was higher in the groups in which the normal  \nvitamin D status was restored, however, the \ndifference between the groups was not as \npronounced as when comparing other \ninterleukins in groups. IL -4 blocks the stimulated  \nand spontaneous production of other pro- \ninflammatory cytokines (IL-1β, IL-6, TNF-α), but \nits activity in these studies was not very \npronounced. Probably, the high IL -6 level in the  \n1st group is compensatory and could indicate \nantitumor processes activation on the \nbackground of increased inflammatory processes  \nand restoration of neoangiogenesis (Radzinskiy \net al., 2016), confirmed by high VEGF-R1 level \nof. The lowest VEGF-R1 level was observed in \nthe group of women receiving the correction of  \nvitamin D deficiency together with hormone \ntherapy. However, the assessment of the plasma  \nlevel of the vascular endothelial factor was \nambiguous. In general, it was found that cytokine  \nstatus indicators significantly differed in groups \ndepending on the saturation of the body with \nvitamin D. \nPregnancy rates varied markedly in \ngroups. In the first group, the fact of spontaneous  \npregnancy was recorded in 21.7% (13) of the \nobservations, in the second - in 35.0% (21) of the \npatient, in the third - in 48.3% (29) and in 4th - \n51.7% (31). At the same time, the frequency of  \nundeveloped pregnancy in the groups, in general, \n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n255 \n \nwas higher in 13.3% (8) in the 1st group and in \nthe 2nd group - 10.0% (6), and much less \nfrequently in the 3rd group 6.7 % (4) and in the \n4th group - 5.0% (2) (p = 0.94). Repeated \ndetermination of VEGF-R1 level in these patients  \nshowed a sharp increase by 1.3 -2.1 times at the  \ntime of pregnancy termination. Thus, in the 1st  \ngroup it was 257.4 ± 21.4 ng / ml, in the 2nd \ngroup - 203.2 ± 14.2 ng / ml, in the 3rd group - \n246.4 ± 17.7 ng / ml and in the 4th group - 221.4 \n± 19.2 ng / ml (p˂0.0085). According to Cöl- \nMadendag et al. (2014), early abortion at the \nearly sate of pregnancy termination is a result of \na disturbance in the interaction of VEGF with its  \nreceptors in the mother -fetus system (VEGFR1  \nand VEGFR2): a significant decrease in receptor  \nexpression occurs (Volkova and Alyautdina, \n2011). \nMean VEGF-R1 level in the blood serum \nof spontaneously pregnant women was 1.3-1.5 \ntimes lower than in the groups in general and \namounted to 134.9 ± 35.5 ng / ml in the 1st group  \nand 94.7 ± 11.9 ng / ml in the 2nd group, 114.4 ± \n25.9 ng / ml in the 3 group and 95.1 ± 15.5 ng / \nml in the 4 group, which significantly correlated  \nwith the pregnancy rate in groups (r1 = - 0.45; r2 = \n- 0.55; r3 = - 0.48; r4 = - 0.41; p 0.40.0085). The \nIVF procedure was completed in 28.3% of the \npatients in the 1st group, 25.0% in the 2nd group,  \n21.7% in the 3rd group, and 21.7% in the 4th \ngroup. As a result of IVF, pregnancy occurred in  \n8.3% in the 1st group, 8.3% in the 2nd group,  \n10.0% in the 3rd group, and 11.7% in the 4th \ngroup. It was found that in women who became  \npregnant as a result of IVF, the level of the \nvascular endothelial factor  was 1.2 - 1.7 times \nhigher and amounted to 227.1 ± 13.4 ng / ml,  \n215.3 ± 32.3 ng / ml, 228.5 ± 27, 175.4 ± 38.1 ng \n/ ml in groups, respectively. \nThe observed total vitamin D deficiency in  \nwomen with EGE is consistent with the results of  \nstudies by other authors. For example, a \nprospective cohort study in the USA that included  \n70,566 patients showed that there is an inverse  \ncorrelation between 25 (OH) D level and the \nincidence of endometriosis. In women with \nnormal vitamin D levels (located in the upper \nquartile), the incidence of endometriosis was 25% \nlower than in those in whom the vitamin D plasma \nlevel was within the lower quartile (RR = 0.76;  \n95% CI: 0.60- 0.96; p = 0.004) (Merhi et al., \n2014). The absence of difference in vitamin D \nsaturation of the body of the examined women by  \nseasons is most lik ely due to the fact that the  \nstudy was performed in a region without marked  \nfluctuation in the length of day and night in \nseasons, which can be observed in more \nnorthern regions, the number of sunny days does  \nnot depend on the time of the year, and there are  \nalso cultural characteristics of nutrition, with \nprevalence of flour foods, and wearing clothes \ncovering most of the body, including the head. \nModern ideas on endometriosis \npathogenesis of show that this di sease meets all  \nthe criteria for autoimmune diseases, because \ninflammation is observed on the background of  \nimpaired immune regulation. Studies by C.A. \nGysemans et al. (2014) prove the anti- \ninflammatory, antiproliferative, and \nimmunomodulatory features of vitamin D the \neffect on the body by affecting the synthesis of  \ncertain pro-inflammatory cytokines, preventing \ntranscription of a number of their genes \n(Gysemans et al., 2014). IL-6, IL-1β, and TNF -α \nactivation, registered in ou r study in women with  \nvitamin D lack or deficiency, shows systemic \ninflammation leading to changes in the peritoneal  \nfluid, which, in turn, affects the quality and activity  \nof sperm , slows down the acrosomal interaction  \nand association of sperm with oocyt e, decreased \nfertility (Delvin et al., 2014; Gysemans et al., \n2014; Irani et al., 2015; Orazov, 2015; Paffoni et \nal., 2014). Normalization of vitamin D status leads \nto changes in the cytokine ratio, which is \nconfirmed by еру increaseв number of \npregnancies in the examined groups by 1.6 times  \nonly with the correction of vitamin D deficiency  \nand 2.4 times with correction of insufficiency on  \nthe background of hormonal treatment with \ndienogest. \nModern literature indicates the special role \nof neovascularization in endometriosis \npathogenesis (Radzinskiy et al., 2016). The \nprocesses of significant neovascularization and \nneurogenesis activation in ectopic foci in external  \ngenital endometriosis were revealed. Already in  \nthe early stage of endometrioid heterotopia, an  \nincreased density of blood vessels, widening of  \ntheir lumen, and increase in the number of \n“immature vessels” are observed (Burlev, 2016;  \nHuang et al., 2014). The main trigger factor for  \nangiogenesis and vasculogenesis in physiological \nconditions and pathology is the vascular \nendothelial growth factor. Besides, VEGF as a \nstrong factor in vascular permeability and \nleukocyte mobilization is involved in the \ndevelopment of the inflammatory process (Cöl- \nMadendag et al., 2014; Demir et al., 2010; \nLaschke et al., 2011; Radzinskiy et al ., 2016). \nThe decreased parameters of vascular \nendothelial growth factor in the groups with \nnormal vitamin D levels and the inverse \n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n256 \n \nrelationship between the moderate rate of \npregnancy and VEGF level in the blood can \nconfirm the effectiveness of the indirect vitamin D  \neffect on neovascularization processes. However, \nthe literature data is ambiguous. Thus, in non - \npregnant patients with tubal-peritoneal infertility \nfactor, a 1.5-fold increase in serum VEGF in \ncomparison with women who have positive ECF  \ntreatment results (Gerilovich et al., 2013). In our  \nstudy, in women who became pregnant as a \nresult of ECF, the level of the vascular endothelial \nfactor was 1.2 - 1.7 times higher. Such \nmultidirectional parameters may indicate that in  \ninfertility on the background of endometriosis, \npregnancy can only occur on the backgrou nd of \npronounced stimulation of angiogenesis. \n \n4. CONCLUSIONS \n \nThe data obtained show that correction of  \nvitamin D insufficiency on the background of \ndienogest therapy allows increasing efficiency of  \nEGE symptom treatment and favors \nimpregnation. \nIn vitamin D status correction in women  \nwith EGE and infertility, the best indicators of \nimmune (cytokine) status were noted. IL -6, IL-1β \nand TNF-α high level in groups with a low vitamin  \nD content indicates a high immune tension in the  \nbody, which negatively affects impregnation. \nThe deficiency of vitamin D correction is  \naccompanied by the increased the number of \npregnancies in the examined groups by 1.6 times  \nonly with the correction of vitamin D deficiency  \nand 2.4 times with the correction of insufficien cy \non the background of hormonal treatment with \ndienogest. \nA significantly moderate inverse \ncorrelative relationship was found between \nVEGF-R1 serum level and the probability of \npregnancy in women with EGE after surgical \ntreatment (from -0.41 to -0.55). \nThus, the obtained data indicate the need  \nfor further study, the generalization of data on \nvitamin D role in the pathogenesis of external \ngenital endometriosis, infertility associated with it, \nand its therapeutic effects. \n \n5. REFERENCES \n \n1. Adamyan, L. V., Aznaurova, Ya. 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Clinical \nand diagnostic value of vascular endothelial \ngrowth factor in unsuccessful ECF \nattempts. Obstetrics and Gynecology, \n2011, 4, 126–129. \n23. Yarmolinskaya, M. I., Ailamazyan, E. K. \nGenital endometriosis. Different aspects of  \nthe problem. St. Petersburg: Eco-Vector, \n2017. \n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n258 \n \nTable 1. The cytokine composition in the blood serum of patients with EGE in groups with and without \nvitamin D deficiency \n \nParameter Group 1 Group 2 Group 3 Group 4 \nIL-1β, pg/ml 15.94±2.41 8.27±2.75 11,82±1.24 6.36±1.87 \nSignificance of differences р1-2=0.0041 р2-4=0.0076 р3-4=0.0061 р1-4=0.0015 \nIL-6, pg/ml 7.51±2.18 4.17±2.74 5.93±2.27 4,35±1,71 \nSignificance of differences р1-2=0.0001 р2-4=0.0087 р3-4=0.0035 р1-4=0.0019 \nTNF-α, pg/ml 15.49±2.73 9.23±3.51 11.01±3.68 7.75±2.79 \nSignificance of differences р1-2=0.0052 р2-4=0.0071 р3-4=0.0078 р1-4=0.0024 \nIL-4, pg/ml 14.35±4.17 18.73±5.77 13.48±4.83 17.87±4.92 \nSignificance of differences р1-2=0.0075 р2-4=0.0094 р3-4=0.0043 р1-4=0.0076 \nVEGF-R1, ng/ml 198.1±72.1 127.2±69.1 176.3±74.7 103.4±61.2 \nSignificance of differences р1-2=0.0055 р2-4=0.0074 р3-4=0.0028 р1-4=0.0021 \n \n \n \n \n \nFigure 1. The level of concentration of vitamin D in the examined groups during the initial examination \n(ng / ml) \n\n\nPeriódico Tchê Química. ISSN 2179-0302. (2020); vol.17 (n°34) \nDownloaded from www.periodico.tchequimica.com \n259 \n \n \nFigure 2. Pain syndrome dynamics in the examined patients depending on the treatment \nmethods during one year after surgery. \n \n \nFigure 3. Dynamics of menstrual cycle disturbance in the examined patients depending on treatment \nmethods during one year after surgery \nThe Periódico Tchê Química (ISSN: 1806-0374; 2179-0302) is an open-access journal since 2004. Journal DOI: 10.52571/PTQ. http://www.tchequimica.com.  \nThis text was introduced in this file in 2021 for compliance reasons.  \n© The Author(s) OPEN ACCESS.  \nThis article is licensed under a Creative Commons Attribution 4.0 (CC BY 4.0) International License , which permits use, sharing , ad aptation , distribution , and reproduction in any medium or format, as long as you give \nappropriate credit to the original author ( s) and the source , provide a link to the Creative Commons license , and indicate if changes were made. The images or other t hird-party material in this article are included in the \narticle ’s Creative Commons license unless indicated otherwise in a credit line to the material . If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. 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