{"paper_id":"30a1a0e3-aaa3-423c-bf01-18d03c7d16cc","body_text":"Endometriosis is a common gynecological disease, which affects approximately from 2 to 10 % of women in reproductive age. Patients with endometriosis suffer from pelvic pain, dyspareunia, dysuria, dysmenorrhea, and they constitute about 50 % of infertile women (Dunselman et al.  2014 ). Endometriosis is defined as the presence of functional endometrial tissue outside the uterine cavity, mostly in the pelvic peritoneum, ovaries, and rectovaginal septum (Burney and Giudice  2012 ; Gupta et al.  2008 ; The Practice Committee of the American Society for Reproductive Medicine  2012 ). Several hypotheses have attempted to explain the etiology and pathogenesis of endometriosis, mainly Sampson’s theory of retrograde menstruation of the endometrial tissue through the fallopian tubes and into the peritoneal cavity, and its subsequent implantation (Sampson  1927 ). It has been suggested that a defect of the natural killer (NK) activity in the recognition and lysis of these implanted endometrial cells may be one of the crucial points in the initiation and progression of endometriosis (Berkkanoglu and Arici  2003 ).\nNatural killer cells can express killer immunoglobulin-like receptors (KIR), which recognize class I human leukocyte antigens (HLA) on target cells and may either stimulate or inhibit NK cell activity. KIR receptors occur as two or three extracellular immunoglobulin-like domain molecules with a long (L) or short (S) cytoplasmic tail. KIR2DL/KIR3DL has inhibitory function in contrast to KIR2DS/3DS with activating function.  KIR  genes exhibit extensive haplotypic and allelic polymorphism. Individuals differ in both the number and kind (activating vs. inhibitory) of  KIR  genes (Middleton and Gonzelez  2010 ; Falco et al.  2013 ; Kulkarni et al.  2008 ).\nHLA-C molecules can be divided into two groups, HLA-C C1 and C2, according to the amino acid present at position 80 of the molecule. All HLA-C molecules with asparagine at position 80 belong to the HLA-C C1 group, and are recognized by KIR2DL2/2DS2 and KIR2DL3, whereas those with lysine in this position belong to the HLA-C C2 group and constitute ligands for KIR2DL1/2DS1. However, KIR2DL2/2DL3 may also bind to some C2 molecules. KIR2DS4 binds HLA-A11 and some C1 and C2 molecules (Graef et al.  2009 ). Finally, KIR3DL1 has specificity for HLA-Bw4 epitope (Middleton and Gonzelez  2010 ; Falco et al.  2013 ; Kulkarni et al.  2008 ).\nKIR  and  HLA  polymorphism affects NK cell reactivity and susceptibility to various diseases (Kulkarni et al.  2008 ). The aim of our study was to find an association of  KIR  genes and their  HLA  ligands with susceptibility to endometriosis in Polish women. To our knowledge, this is the first study in females emphasizing the role of  KIR2DS5  and  KIR2DS4  deletion variant ( KIR2DS4del ) in clinical stages of endometriosis.\n\nOne hundred and fifty-three Polish patients with endometriosis (age range, 20–58 years; mean ± S.D., 33.7 ± 8.0 years) diagnosed at the First and Second Department of Obstetrics and Gynecology, Medical University of Warsaw for pelvic pain, dysmenorrhea, and/or infertility were included in the study. Patients were classified according to the revised American Fertility Society criteria (American Fertility Society  1985 ) and both laparoscopic and histopathological examinations. All patients were categorized into four subgroups: I–II—minimal and mild stages, III—moderate, and IV—severe stages. Among them, 98 (64.1 %) patients manifested ovarian endometriosis, 43 (28.1 %) patients had ovarian and peritoneal endometriosis, and 12 (7.8 %) patients had only peritoneal endometriosis.\nThe control group consisted of 213 women. Among this group, 96 women were anonymous adults from paternity testing, who gave birth to at least one child, but there was no information on the disease status as they were anonymous. The remaining 117 women (age range, 23–68 years; mean age ± S.D., 31.37 ± 6.36) reported having at least two babies with the same partner and no gynecological, endocrinological, or immunological disorders (described earlier by Nowak et al.  2009 ). Experimental protocols were approved by the Local Ethics Committee and all patients gave their informed consent to the study.\nGenomic DNA was isolated from venous blood using the salting out method or using an Invisorb Spin Blood Midi Kit (Invitek, Berlin, Germany) following the manufacturer’s instructions.  KIR  genotyping was described previously by Nowak et al. ( 2009 ) and Sun et al. ( 2004 ). Our  KIR  typing is validated three times a year by the International KIR Exchange Program organized by the Immunogenetics Center of the University of California at Los Angeles.\nHLA-C  gene fragments determining the  HLA-C1  and  C2  groups were distinguished according to a PCR-SSP method described by Frohn et al. ( 1998 ).  HLA-Bw4  and  HLA-Bw6  alleles were genotyped as described in Supplement  1 .\nThe proportion of individuals positive for a given  KIR  gene as well as  HLA-C1  and  C2  groups and  HLA-Bw4  was established by direct counting.  KIR  gene frequencies (gf) were estimated using the formula gf = 1 − √(1 − pf), where pf is the proportion of the population positive for the gene. Odds ratio and its 95 % confidence interval were used as a measure of effect size. Generalized linear models with binomial errors and the chi-square test for trend were used to investigate the relationship between clinical and genetic variables. Akaike’s information criterion was used as a measure of fit of models. Confidence intervals were estimated with the  bootstrap  approach.  P  values were computed exactly by numerical simulations. Measures for the estimation of linkage disequilibrium (LD) were the correlation of two alleles’ frequencies,  r , global squared correlation between two loci,  R \n 2  and Kullback-Leibler divergence of two loci from LE (Excoffier and Slatkin  1995 ; Abdallah et al.  2003 ). For the two loci  2DS4  and  2DS5 ,  r  and  R \n 2  were obtained as:  \\documentclass[12pt]{minimal}\n\t\t\t\t\\usepackage{amsmath}\n\t\t\t\t\\usepackage{wasysym} \n\t\t\t\t\\usepackage{amsfonts} \n\t\t\t\t\\usepackage{amssymb} \n\t\t\t\t\\usepackage{amsbsy}\n\t\t\t\t\\usepackage{mathrsfs}\n\t\t\t\t\\usepackage{upgreek}\n\t\t\t\t\\setlength{\\oddsidemargin}{-69pt}\n\t\t\t\t\\begin{document}$$ r=\\frac{D_{ij}}{\\sqrt{p_i{q}_j}} $$\\end{document} r = D i j p i q j , where  p \n i  and  q \n j  are the population allele frequencies of the  i th allele on locus 2DS4 and the  j th allele on locus  2DS5, D \n ij  =  x \n ij  −  p \n i \n q \n j , and  x \n ij  is the frequency of the haplotype with alleles  i  and  j  on loci  2DS4  and  2DS5 , respectively.  \\documentclass[12pt]{minimal}\n\t\t\t\t\\usepackage{amsmath}\n\t\t\t\t\\usepackage{wasysym} \n\t\t\t\t\\usepackage{amsfonts} \n\t\t\t\t\\usepackage{amssymb} \n\t\t\t\t\\usepackage{amsbsy}\n\t\t\t\t\\usepackage{mathrsfs}\n\t\t\t\t\\usepackage{upgreek}\n\t\t\t\t\\setlength{\\oddsidemargin}{-69pt}\n\t\t\t\t\\begin{document}$$ {R}^2={\\displaystyle {\\sum}_i^3{\\displaystyle {\\sum}_j^2\\frac{D_{ij}^2}{p_i{q}_j}.}} $$\\end{document} R 2 = ∑ i 3 ∑ j 2 D i j 2 p i q j .  Kullback-Leibler divergence (Bhasi et al.  2006 ; Liu and Lin  2005 ),  D \n KL  is a measure of distance between the observed haplotype distribution and the expected distribution assuming LE:  \\documentclass[12pt]{minimal}\n\t\t\t\t\\usepackage{amsmath}\n\t\t\t\t\\usepackage{wasysym} \n\t\t\t\t\\usepackage{amsfonts} \n\t\t\t\t\\usepackage{amssymb} \n\t\t\t\t\\usepackage{amsbsy}\n\t\t\t\t\\usepackage{mathrsfs}\n\t\t\t\t\\usepackage{upgreek}\n\t\t\t\t\\setlength{\\oddsidemargin}{-69pt}\n\t\t\t\t\\begin{document}$$ {D}_{\\mathrm{KL}}={\\displaystyle {\\sum}_i^3{\\displaystyle {\\sum}_j^2{x}_{ij} log\\frac{x_{ij}}{p_i{q}_j}.}} $$\\end{document} D K L = ∑ i 3 ∑ j 2 x i j log x i j p i q j .  The chi-square statistic was calculated to test whether all of the  D \n ij ’s between 2DS4 and 2DS5 are zeros:  \\documentclass[12pt]{minimal}\n\t\t\t\t\\usepackage{amsmath}\n\t\t\t\t\\usepackage{wasysym} \n\t\t\t\t\\usepackage{amsfonts} \n\t\t\t\t\\usepackage{amssymb} \n\t\t\t\t\\usepackage{amsbsy}\n\t\t\t\t\\usepackage{mathrsfs}\n\t\t\t\t\\usepackage{upgreek}\n\t\t\t\t\\setlength{\\oddsidemargin}{-69pt}\n\t\t\t\t\\begin{document}$$ {\\chi}_{df=2}^2={\\displaystyle {\\sum}_i^3{\\displaystyle {\\sum}_j^2\\frac{n{D}_{ij}^2}{p_i{q}_j}.}} $$\\end{document} χ d f = 2 2 = ∑ i 3 ∑ j 2 n D i j 2 p i q j .\n\nThe frequencies of  KIR  genes in patients were similar to the frequencies observed in control women (Table  1 ) except for  KIR2DS5 . This latter result has already been described, but without analysis of other  KIR  genes (Nowak et al.  2010 ). The presence of  KIR2DS5  significantly decreased the risk of endometriosis. The  KIR2DS5  effect was independent from other  KIR  genes, including  KIR2DS4  ( P  = 0.181). However, it was seen only in  HLA-C C2 -positive individuals: in this group, those who possessed  KIR2DS5  had 2.5 lower chance of getting endometriosis than KIR2DS5-negative women (Supplement  2 ). In contrast,  KIR2DS5  presence did not affect the risk of disease in  C2 -negative individuals (Supplement  2 ). Noteworthy,  C2  presence or absence itself had no relation to disease risk ( P  = 0.363). Similarly, there was no correlation of  HLA-Bw4  or  HLA-Bw6  with disease (data not shown). Table 1 \n KIR  gene frequencies in patients and controls Group KIR gene 2DL1 2DL2 2DS3 2DL3 2DS2 3DL1 3DS1 2DL5 2DS1 2DS4fl 2DS4del 2DS4 2DS5 Patients,  N \n 147 89 61 135 91 147 51 79 60 51 125 147 33 * \n gf a \n 80.3 35.3 22.5 65.6 36.4 80.3 18.3 30.4 22.0 18.3 57.2 80.3 11.5 Controls,  N \n 205 115 70 188 116 201 85 113 94 61 181 201 68 gf 80.5 32.2 18.1 65.8 32.5 76.3 22.5 31.4 25.2 15.5 61.3 76.3 17.5 OR 0.96 1.19 1.35 1.0 1.23 1.46 0.75 0.94 0.82 1.25 0.79 1.46 0.58 \n N  number of cases,  p  probability,  OR  odds ratio,  95 % CI  confidence interval Patients vs controls, * P  = 0.033, 95 % CI = 0.36–0.95 \n a gf, gene frequency calculated according to the formula gf = 1 − √(1 − pf)\nKIR  gene frequencies in patients and controls\nN  number of cases,  p  probability,  OR  odds ratio,  95 % CI  confidence interval\nPatients vs controls, * P  = 0.033, 95 % CI = 0.36–0.95\na gf, gene frequency calculated according to the formula gf = 1 − √(1 − pf)\nWe also analyzed the genetics of peritoneal versus ovarian endometriosis (Table  2 ).  KIR2DS5 -positive,  KIR2DS4del -negative women with endometriosis had 13 times lower chance that the disease would occupy the peritoneum than  KIR2DS5-  and  KIR2DS4del -negative ones (OR = 0.077,  P  = 0.0061). The percentage of individuals with peritoneal endometriosis in  KIR2DS5- positive,  KIR2DS4del -negative persons was only 25 % in comparison to 81 % in the double-negative group. Similarly,  KIR2DS5- negative,  KIR2DS4del -positive, endometriotic persons had lower (almost 11 times) chance for peritoneal disease in relation to double negative ones (OR = 0.094,  P  < 0.001). Interestingly, although double positive ( KIR2DS5 \n + ,  KIR2DS4del \n + ) genotype had also a decreased chance of peritoneal endometriosis, in this case the protective effect was weaker (Table  2 ): this form of disease was present in nearly 43 % of patients with this genotype.  KIR2DS4-full-length  gene presence was not related to severity of disease (data not shown).  KIR2DS5  and  KIR2DS4  genes are in a strong negative linkage disequilibrium, as reflected by a complete lack of haplotype positive both for  KIR2DS5  and  KIR2DS4del  (more frequent variant of  KIR2DS4 ) in the control group (Table  3 ). This haplotype is also absent from women with ovarian endometriosis, but present in 4 % of patients with peritoneal form of disease (Table  3 ). Table 2 Chance of peritoneal endometriosis depending on  KIR2DS5/2DS4del  genotype 2DS5 2DS4del Peritoneum Number Percent OR 95 % CI \n P  value + − − − 13 3 16 81.25 1 – – – + + 9 12 21 42.86 0.173 0.038 0.795 0.041 + − 3 9 12 25.00 0.077 0.012 0.478 0.0061 − + 30 74 104 28.85 0.094 0.025 0.356 <0.001 Two-sided Fisher’s exact test was used to estimate differences between patients with peritoneal and non-peritoneal endometriosis \n N  number of cases with relevant genotype,  p  probability,  OR  odds ratio,  95 % CI  confidence interval \n Table 3 Linkage disequilibrium between two loci:  KIR2DS4  and  KIR2DS5 \n Group Haplotypes 2DS4 full /2DS5 2DS4 del /2DS5 ―/2DS5 2DS4 full /― 2DS4 del /― ―/― Controls HFs 0.0019 0 0.1724 0.153 0.6172 0.0555 \n r \n −0.153 −0.328 0.666 0.07 0.151 −0.306 \n R \n 2  = 0.6952 \n D \n KL  = 0.4701 \n χ \n 2  = 148.77; df = 2;  P  < 0.00001 Peritoneum+ HFs 0 0.0422 0.0867 0.1976 0.5245 0.149 \n r \n −0.16 −0.114 0.323 0.061 0.044 −0.124 \n R \n 2  = 0.1639 \n D \n KL  = 0.1473 \n χ \n 2  = 9.178; df = 2;  P  = 0.01016 Peritoneum− HFs 0.0044 0 0.1077 0.15 0.6707 0.0671 \n r \n −0.098 −0.274 0.629 0.035 0.097 −0.224 \n R \n 2  = 0.5413 \n D \n KL  = 0.3093 \n χ \n 2  = 53.59; df = 2;  P  < 0.00001 \n HFs  haplotype frequencies,  D \n KL  Kullback-Leibler divergence from linkage equilibrium,  R \n 2  global squared correlation coefficient for two loci,  r  correlation coefficient for allele frequencies, ― lack of a given gene ( KIR2DS4  and/or  KIR2DS5 ),  Peritoneum+  and  Peritoneum− , the presence or absence of peritoneal endometriosis\nChance of peritoneal endometriosis depending on  KIR2DS5/2DS4del  genotype\nTwo-sided Fisher’s exact test was used to estimate differences between patients with peritoneal and non-peritoneal endometriosis\nN  number of cases with relevant genotype,  p  probability,  OR  odds ratio,  95 % CI  confidence interval\nLinkage disequilibrium between two loci:  KIR2DS4  and  KIR2DS5\nR \n 2  = 0.6952\nD \n KL  = 0.4701\nR \n 2  = 0.1639\nD \n KL  = 0.1473\nR \n 2  = 0.5413\nD \n KL  = 0.3093\nHFs  haplotype frequencies,  D \n KL  Kullback-Leibler divergence from linkage equilibrium,  R \n 2  global squared correlation coefficient for two loci,  r  correlation coefficient for allele frequencies, ― lack of a given gene ( KIR2DS4  and/or  KIR2DS5 ),  Peritoneum+  and  Peritoneum− , the presence or absence of peritoneal endometriosis\nLast but not least, the severity of disease seemed to be associated with the  KIR2DS4del  gene, as the frequency of  KIR2DS4del  was increased in higher disease stages (Table  4 ). No other genes had any effect on the severity of endometriosis (data not shown). Table 4 Frequency of  KIR2DS4del  positivity depending on endometriosis stage Group Disease stage I + II III IV 2DS4del− 5 9 6 2DS4del+ 7 33 49 % 58.33 78.57 89.09 \n P \n 0.012 The chi-square test for trend was used to investigate the relationship between clinical and genetic variables \n p  probability,  I + II  minimal and mild endometriosis,  III  moderate,  IV  severe\nFrequency of  KIR2DS4del  positivity depending on endometriosis stage\nThe chi-square test for trend was used to investigate the relationship between clinical and genetic variables\np  probability,  I + II  minimal and mild endometriosis,  III  moderate,  IV  severe\n\nEndometriosis is an enigmatic disease, in which many factors—genetic (Montgomery et al.  2008 ), neuroendocrine (Tariverdian et al.  2007 ), immunological (Tariverdian et al.  2007 ; Matarese et al.  2003 )—are involved in the pathogenesis. The most accepted “transplantation theory” (Sampson  1927 ) explains the presence of the majority of endometriotic lesions in the peritoneal cavity by insufficient immune surveillance. Retrograde menstruation happens in up to 90 % of women in reproductive age. However, only minority of these women develop endometriosis. Therefore, it is generally accepted that changes in the activity of immune cells in the peritoneal microenvironment play an important role in the etiology of this disease (Berkkanoglu and Arici  2003 ; Matarese et al.  2003 ; Dmowski and Braun  2004 ; Ulukus et al.  2006 ). Particularly, it has been shown that NK cells of peripheral blood and peritoneal fluid of endometriotic patients exhibit decreased cytotoxicity to autologous endometrium (Oosterlynck et al.  1991 ;  1992 ). This impaired activity also correlated with severity of the disease. Moreover, Japanese scientists found an increased percentage of KIR2DL1-positive NK cells in peritoneal fluid and peripheral blood of women with pelvic endometriosis, which suggests stronger inhibition of NK cell activity against ectopic endometrium (Maeda et al.  2002 ). Individual NK cells differ in their KIR repertoire because this results from stochastic KIR expression in individual clones (Parham  2005 ). Nevertheless, a high degree of genotypic polymorphism (i.e., the presence or absence of particular  KIR  genes in the genotype of a given individual) allows NK cells to express only those  KIR  genes which are present in their genotype. Therefore, we looked for possible associations of  KIR  genes with susceptibility to endometriosis, localization of lesions (ovarian versus peritoneal), and severity of the disease.\nWe previously described decreased frequency of  KIR2DS5  in patients with endometriosis in comparison to healthy control (Nowak et al.  2010 ) but other  KIR  genes were not analyzed there. Here, we report the protective effect of  KIR2DS5  only in females who possessed the  HLA-C  C2 group. The  KIR2DS5  gene has been proven to be expressed at both the mRNA (Della Chiesa et al.  2008 ) and protein (Steiner et al.  2014 ) level, although it has been reported that its transcript could be detected in only 10 % of individuals positively genotyped for this gene (Leung et al.  2005 ), and protein expression of different alleles varies (Steiner et al.  2014 ). However, analysis of KIR expression at the protein level is difficult because of cross-reactivity of available antibodies, especially between inhibitory and activating receptors, which frequently have very similar amino acid sequences in their extracellular domains. Recently, it has been shown that monoclonal antibodies 143211 and HPMA4, which were previously thought to be specific exclusively for KIR2DL1 and KIR2DS1/L1, respectively, also bind KIR2DS5 (143211) or KIR2DS5 and KIR2DS3 (HPMA4) (Czaja et al.  2014 ). Therefore, studies showing increased expression of KIR2DL1 but not other KIRs in women with pelvic endometriosis (Maeda et al.  2002 ) should be treated with caution.\nA physiologic ligand for KIR2DS5 is unknown (Parham et al.  2012 ). However, circumstantial evidence suggests that it may interact with both C1 and C2, because, in hematopoietic stem cell transplantation, leukemia-free survival and relapse rate depended on the presence or absence of the donor  KIR2DS5  gene as well as on the  C1/C2  versus  C1/C1  or  C2/C2  genotype of the recipient (van der Meer et al.  2008 ). Our finding, mentioned above, also suggests an interaction between KIR2DS5 and HLA-C molecules, influencing the ability of KIR2DS5+ NK cells to eliminate ectopic endometrium in C2+ women. Interestingly,  KIR2DS5  was found protective against another gynecological disorder, pre-eclampsia, in British Europeans and Ugandan Africans, and fetal  C2  inherited from the father increased the risk of disease in  KIR2DS5 -negative women (Nakimuli et al.  2015 ). However, only one allele,  KIR2DS5*006 , was protective in Ugandans, and this allele is absent from European populations, possessing only  KIR2DS5*002  if any (Hou et al.  2009 ; Gonzalez-Galarza et al.  2015 ). Therefore, it might be that different  KIR2DS5  alleles affect pre-eclampsia and endometriosis.\nMoreover, we observed preferential non-peritoneal localization of lesions in patients possessing either the  KIR2DS5  or  KIR2DS4del  gene, whereas simultaneous presence of both genes had a weaker effect. Interaction between these two genes has also been found recently in renal transplantation, where we detected a protective effect of the  KIR2DS5  gene against acute graft rejection, but only in the absence of  KIR2DS4del  (Nowak et al.  2012 ). Interestingly, the effect of the  KIR2DS4 - full-length  gene on the graft protection associated with  KIR2DS5  was opposite, i.e.,  KIR2DS5  was protective only if  KIR2DS4  full-length was present (Nowak et al.  2012 ). Here, we observed a much lower percentage of peritoneal endometriosis in women possessing either the  KIR2DS5  or  KIR2DS4del  gene than when both were present. Moreover, even in the subgroup of  KIR2DS5 +/ KIR2DS4del + patients, the fraction with peritoneal lesions was twice as low as in women negative for both these genes. However, the numbers were too small to draw a firm conclusion.\nKIR2DS5  and  KIR2DS4  genes are in strong negative linkage disequilibrium in our population (Table  3  and Niepiekło-Miniewska et al.  2013 ), and  KIR2DS4del  and  KIR2DS4-full-length  are alleles. Therefore, individuals positive for  KIR2DS5  and  KIR2DS4del  are highly unlikely to possess  KIR2DS4-full-length ; similarly, individuals positive for  KIR2DS5  and  KIR2DS4-full-length  are highly unlikely to be  KIR2DS4del -positive. In peritoneal endometriosis, we observed only a weak effect of  KIR2DS4del  on  KIR2DS5  association with lack of endometrial lesions in the peritoneum, and no effect of  KIR2DS4-full-length. KIR2DS4-full-length  variant and  KIR2DS5  had frequencies of only 18.3 and 11.5 % in our patients, respectively, so the number of women with peritoneal endometriosis ( N  = 55) was perhaps too small to detect the interaction of  KIR2DS4-full-length  with  KIR2DS5  similar to that observed in kidney graft rejection.\nPatients with endometriotic lesions limited to the peritoneum belong to a group of mild severity of this disease. NK cells may have the potential to remove endometriotic tissues from the peritoneal cavity but may not have such easy access to ovarian cysts, which are associated with more severe manifestation of endometriosis. Associations of  KIR2S5  and  KIR2DS4del  with protection from peritoneal but not ovarian lesions in endometriotic patients suggest that peritoneal endometriosis may have a different genetic background than ovarian endometriosis. Indeed, the same  KIR2DS4del  which was associated with protection from peritoneal lesions was associated with the highest grades of endometriosis which encompass ovarian lesions.\nThe only report on  KIR  gene associations with endometriosis published so far in addition to our  KIR2DS5  paper (Nowak et al.  2010 ) is that by Kitawaki et al. ( 2007 ), who described decreased frequency of  KIR3DS1  and increased frequency of highly inhibitory KIR-HLA combinations. This result is somewhat similar to ours, because  KIR  haplotypes consisting mostly of inhibitory  KIR  genes (called A haplotypes) are lacking  KIR2DS5  although not  KIR2DS4  (Jiang et al.  2012 ). In addition, we also observed slightly decreased presence of  KIR3DS1  in patients with endometriosis but it was not significant. The Japanese population demonstrates different  KIR  gene distribution from Europeans (allele frequency net: Gonzalez-Galarza et al.  2015 ), and is particularly rich in A haplotype homozygotes (Hiby et al.  2004 ).\nIn conclusion, (i) The presence of  KIR2DS5  reduced the risk of disease if a female possessed alleles from group C2 of  HLA-C . (ii) In endometriotic patients,  KIR2DS5  or  KIR2DS4del  presence lowered the risk of localization of lesions in the peritoneum. (iii) On the other hand,  KIR2DS4del  presence in patients was associated with severity of endometriosis, which, due to strong negative LD, may suggest an indirect effect of  KIR2DS5  absence. (iv) Our results suggest a different genetic background of peritoneal and ovarian endometriosis.\nThe presence of  KIR2DS5  reduced the risk of disease if a female possessed alleles from group C2 of  HLA-C .\nIn endometriotic patients,  KIR2DS5  or  KIR2DS4del  presence lowered the risk of localization of lesions in the peritoneum.\nOn the other hand,  KIR2DS4del  presence in patients was associated with severity of endometriosis, which, due to strong negative LD, may suggest an indirect effect of  KIR2DS5  absence.\nOur results suggest a different genetic background of peritoneal and ovarian endometriosis.\nZhang et al. ( 2006 ) proposed KIR and HLA expression studies as an immunodiagnostic parameter for pelvic endometriosis. We believe that our results may support their proposal and extend it to genotyping patients for  KIR2DS4  and  KIR2DS5 , as well as for  HLA-C C1  and  C2 .\n\nBelow is the link to the electronic supplementary material. Supplement 1 (DOCX 14 kb) \n Supplement 2 (DOCX 13 kb)\n(DOCX 14 kb)\n(DOCX 13 kb)","source_license":"CC0","license_restricted":false}