{"paper_id":"7af36a7f-fe4e-47d8-a6ee-6e82ee5ac7f5","body_text":"Original Article  | JOGCR. 2024; 9(5): 498-506 \n     Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \nThe Supplemental Effect of Vitamin-D3 and Omega-3 on Induced \nEndometriosis in Rat Model to Investigate the Inflammatory Response \n \nZahra Shiravani1,2 , Fatemeh Sadat Najib1,3 , Mahvash Alirahimi1 , Elham Askary1,3 ,  \nTahereh Poordast1,3 , Nader Tanideh4 , Shohreh Roozmeh2 , Golsa Shekarkhar5 , Sana Atbaei1 , \nDanilo Porro6,7 , Soudabeh Sabetian3* , Claudia Cava6  \n \n1. Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Science, Shiraz, Iran \n2. Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran \n3. Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran \n4. Department of Pharmacology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran \n5. Department of Molecular Pathology and Cytogenetic, Deghat Pathology Laboratory, Tehran, Iran \n6. Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR), Milan, Italy \n7. NBFC, National Biodiversity Future Center, Palermo, Italy \n \nArticle Info  ABSTRACT \n  \n          10.30699/jogcr.9.5.498 \n \n \n \nBackground & Objective:  The endometriosis treatment was critical due to \ncomplications associated with current drug delivery system. The present study was \nconducted with aim to compare the curative effect of Vitamin D3 (VTD3) and Omega–\n3 (OG3) with Diphereline during the treatment of endometriosis. \nMaterials & Methods: In this study, endometriosis was induced in different groups \ncontaining 60 adult female rats. The rat model was categorized into 6 groups untreated \nand treated (Olive Oil (solvent), VTD3 (42 mcg/kg/day), OG3 (450 mg/kg/day), \nVTD3+OG3, Diphereline (3 mg/kg/day)). The suspension containing combination of \nDiphereline and supplements was injected and treated for 4 weeks to analyze the effect \nof supplements. The interleukin -6 (IL-6) and Tumor necrosis factor – alpha (TNFα) \ninflammatory responses were measured f rom the serum samples while endometrial \nimplants was dissected and histopathological investigation was done. \nResults: At the end of four weeks, pathologic score decreased significantly with \nsimultaneous measurement of inflammation score of endometriotic lesion, size of \nimplant area, IL -6, TNFα response and compared with untreated female rat. No \nsignificant different was observed in groups undergoing treatment of VTD3, OG3 and \nDiphereline. The combined effect of VTD3+OG3 has similar responses with \nDiphereline treated endometrial implants.  \nConclusion: treatment of VTD3 deficiency and making a change in dietary habits of \nhigh-risk population for endometriosis from adolescence may also play a preventative \nrole in adulthood. \nKeywords: Vitamin-D3, Omega -3, Diphereline, Endometriosis, Rat Model, \nCytokine \nReceived:  2023/09/26; \nAccepted: 2024/01/22; \nPublished Online: 18 Aug 2024; \n \n \nUse your device to scan and read the \narticle online \n \n \nCorresponding Information:  \nSoudabeh Sabetian, \nDepartment of Cellular and Molecular \nBiology, Infertility Research Center, Shiraz \nUniversity of Medical Sciences, Shiraz, Iran \n \n \nEmail: soudabehsabet@gmail.com\n   \n \n \nCopyright © 2024, This is an original open-access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License \nwhich permits copy and redistribution of the material just in noncommercial usages with proper citation. \n \n \nIntroduction\nEndometriosis is one of the most common chronic \ndiseases in women. It occurs when the endometrial \nglands and stroma present in ectopic locations \nincluding ovaries, fallopian tubes, cul -de-sacs, and \npelvic cavity (1, 2) . The signs and symptoms of the \ndisease are dysmenorrhea, dyspareunia, chronic pelvic \npain, irregular uterine bleeding, and/or infertility (3, 4). \nEndometriosis is a chronic multifactorial estrogen -\ndependent gynecological disease affecting about 15% \nof all women of reproductive age and has been found \nin 30-50% of infertile women (3, 5) . Immune cells in \nthe peritoneal fluid of a patient with endometriosis \nsecrete cytokines as well as some growth and \nangiogenic factors that stimulate implantation and \nproliferation of misplaced endometrium which h as \nlocal angiogenesis and inflammation. Different types \nof cytokines -TNFα, VEGF, IL1, IL6, and IL10 - are \nenhanced in the peritoneal fluid of a patient with \nendometriosis (6). In the histopathological evaluation, \ninflammation (as a common feature) (7), reduced \napoptosis, and increased angiogenesis have been \ndetected in favor of survival and development of \nendometriotic tissue (1). The etiology of endometriosis \nis ambiguous; however, diet may play an important \n\n\n499 Effect of Vitamin-D3 and Omega-3 on Endometriosis \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nrole in the improvement of endometriosis. I t acts via \naffecting the immune response, smooth muscle \ncontractility, and estrogenic properties (8) . Common \nmedical treatments of this disease such as \ngonadotropin-releasing hormone analog (GnRHa), \nhave severe secondary adverse effects like preventing \npregnancy that cannot be administered over an \nextended period (9). Diphereline belongs to GnRHa \nmedications which is commonly used in the treatment \nof endometriosis (10) . Some researchers reported that \nDiphereline has some side effects on the function of the \nliver and kidneys that may lead to osteoporosis (11). \nEndometriosis is a chronic disease which needs long-\nterm treatment (12, 13), therefore, development of new \nalternative effective medications with limited side \neffects is necessary for treatment of endom etriosis. \nSome previous studies have reported that serum \nvitamin D3 levels were lower in severe endometriosis \nthan normal controls or patients with mild \nendometriosis (14). Vitamin-D3 may change the ratios \nof T -helper cells leading to the alteration of cel l-\nmediated immunity in women suffering from \nendometriosis (5). Vitamin-D3 strongly modulates the \nimmune response by affecting the proliferation and \ndifferentiation of normal and malignant cells (15). A \ncomparative study indicated that the expression of 1 α-\nhydroxylase increases in the endometrium of patients \nwith endometriosis compared to the healthy controls \n(16). Vitamin -D3 increases anti -inflammatory \ncytokines (17-20) and cell apoptosis; on the other hand, \nit suppresses the angiogenesis in vitro and in vi vo \nenvironments (21-24). Omega -3 (another possible \ntreatment of endometriosis) is a polyunsaturated fatty \nacid which has Vitamin -D3-like properties, including \nantiangiogenic, anti-inflammatory, anti-apoptotic, and \nanti-proliferative effects (25, 26) . Endog enous \nproduction of Omega -3 may protect against the \ndevelopment of endometriosis (27) . Furthermore, it is \nsuggested that omega -3 has beneficial therapeutic \npotentials for the endometrial hyperplasia (28). \nThe hypothesis of the present study was that \nVitamin-D3, Omega-3, and their combination might be \npossible candidates for endometriosis treatment \nbecause they are placed among the most frequently \ncited nutrients in terms of the immunomodulatory, anti-\nangiogenic, and anti -proliferative effects. This study \nwas conducted with aim to compare the efficacy of \nVitamin-D3 and Omega -3 with Diphereline as an \neffective treatment of induced endometriosis in rat \nmodels based on clinical and histopathologic findings. \n \nMethods \nThe protocol of the study was approved by the Ethics \nCommittee of Shiraz University of Medical Sciences \n(IR.SUMS.MED.REC.1398.032). Female rats were \nprovided from the animal holding space of Shiraz \nUniversity of Medical Sciences, Iran. Formalin, \nOmega-3, diethyl ether, hematoxylin, and eosin dyes \nwere all purchased from Merck Company, Germany. \nTNF-α and IL-6 enzyme-linked immunosorbent assay \n(ELISA) kits were supplied from Hangzhou \nEastbiopharm, China. Diphereline and Vitamin -D3 \nwere purchased from Ipsen Pharma Biotech, France \nand OSVE from Pharmaceuti cal Co., Iran. In this \nexperiment, 60 female Sprague Dawley rats were \nincluded. The animals were kept in special cages with \na steel mesh roof and the floor was covered with \nsawdust and wood chips under a temperature -\ncontrolled environment (22±2°C and humidity 55±3 \n%) with 12 hours light/dark cycles. The animals were \nhandled according to the standard international \nguidelines for the care and use of laboratory animals. \nEndometriosis was induced according to the \napproach previously presented by Vernon and Wils on \n(29, 30) . Rats were anesthetized through \nintraperitoneal injection of ketamine hydrochloride (80 \nmg/kg, Alfasan, Netherlands) and xylazine 2% (5 \nmg/kg, Al -fasan, Netherlands). Their abdominal \nsurfaces were shaved and disinfected to be prepared for \nthe laparotomy. Their abdomen was also opened by a 4 \ncm incision. A biopsy was taken from one of the uterine \nhorns of each rat, immersed into warm sterile normal \nsaline, and then longitudinally incised into four equal \n5×5 mm pieces. The dissected tissues (implants) were \nligated onto the anterior abdominal surface using \npolyglactin suture. Finally, the abdomen incision was \nclosed using a 4 -0 suture. Four weeks after the first \nsurgery, a second look laparotomy was carried out and \nthe endometrial implants’ viabilit y was proved by \nobserving good vascular supply and pinkish colored \ntissue in contrast to seen necrosis and fibrosis. \nA total of 60 female rats were divided into 6 groups \n(10 rats in each group). The control group \n(endometriosis group without treatment) rec eived 0.5 \nml of saline 0.9%/day, the second group received pure \nolive oil (42 µg/kg/day) as the solvent of Vitamin -D3, \nthe third group took Vitamin -D3 (42 µg/kg/day), the \nfourth group received Omega -3 (450 mg/kg/day), the \nfifth group received Vitamin- D3 (4 2 µg/kg/day) + \nOmega-3 (450 mg/kg/day) for the next 4 weeks. All the \ntreatments of these groups were administered by oral \ngavage. The sixth group received a single IM injection \nof diphereline S.R. 11.25 mg (3 mg/kg, Ipsen, France). \nFour weeks after the treatments, the rats were sacrificed \nand endometrial implants were evaluated (Figure 1). \n \n \n\nZahra Shiravani et al. 500 \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \n \nFigure 1. Endometrial implants in various groups A) Endometriosis group (large size). B) olive oil receiving group (large size \nand the surrounding blood vessels). C)  Vit D receiving group (small size). D) Omega 3 receiving group. E) Vit D+Omega 3 \nreceiving group (small size as well as its lack of growth). F) diphereline receiving group (small size as well as its lack of growth). \n \nBlood samples were obtained from the rats and the \nsera were separated by centrifugation (3500 rpm/10 \nmin). The levels of IL-6 and TNF-α were quantified by \nELISA, based on the manufacturer's instruction. The \nresearcher who performed the test was not aware of the \nintervention done on the rats.   \nPrepared animals were placed in a jar and \nanesthetized by ether and then sacrificed based on \nethical scarifying guidelines. The endometrial implants \nwere dissected from the rats, washed with \nphysiological serum, and put into 10% formalin to be \nprepared for the tissue blocks. Using a tissue processor, \nthe samples were dehydrated, embedded in paraffin,  \nand cut into 5- µm sections. The sections were stained \nwith hematoxylin and eosin and evaluated using a light \nmicroscope by a single experienced pathologist. The \nsamples rendered to the mentioned pathologist (who \nevaluated the main histopathological findin gs) were \nblinded and the pathologist was not aware of the \nintervention done on rats.    \nData were analyzed using SPSS software (version \n25) and parametric one- way ANOVA followed by \nTukey HSD (honestly significant difference) test for \nassessing the IL-6 and TNF-α concentration as well as \nimplants' size. Non-parametric Mann-Whitney test was \nused for measuring pathologic and inflammation \nscores. Data are presented as Mean ± SD (standard \ndeviation). P< 0.05 was considered statistically \nsignificant.  \n \nResults \nThe level of IL -6 and TNF -α in the endometriosis \nand different treated groups are shown in Table 1 . The \nlevel of serum IL -6 after 4 weeks of treatment was \nsignificantly decreased in the Vitamin-D3, Vitamin-D3 \n+ Omega-3 and diphereline receiving groups compared \nto the endometriosis group (p<0.05). All treated groups \nwere compared with the diphereline group as a proven \ntreatment for endometriosis. Interestingly, the findings \nindicated that the level of this cytokine was \nsignificantly diminished in the Vitamin-D3 + Omega3 \nreceiving group compared to the diphereline group \n(p=0.04).  \nThe level of TNF -α was decreased in all treated \ngroups (p≤0. 01), except for olive oil treatment. \nMoreover, the Vitamin-D3, Omega-3 and, Vitamin-D3 \n+ Omega -3 wer e demonstrated no significant \ndifferences in comparison with diphereline group.  \n \n \n \n \n \n \n \n \n\n\n501 Effect of Vitamin-D3 and Omega-3 on Endometriosis \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nTable 1. The level of serum IL-6 and TNF-α  \n IL6 (pg/ml) TNF-α (pg/ml) \nGroups Mean ± SD P val 1 P val 2 Mean ± SD P val 1 P val 2 \nEndometriosis 254.80 ± 30.10 ------ ------ 430.23 ± 87.21 ------ ------ \nOlive oil 244.85 ± 29.17 0.55 0.003 417.01 ± 76.23 0.77 < 0.001 \nVitamin D3 180.40 ± 27.59 0.001 0.89 246.42 ± 23.75 0.003 0.187 \nOmega3 201.04 ± 38.07 0.02 0.39 275.04 ± 70.61 0.01 0.98 \nVitaminD3 + \nOmega3 138.28 ± 37.12 < 0.001 0.04 229.08 ± 35.45 < 0.001 0.71 \nDiphereline 182.57 ± 37.31 0.002 ------- 221.01 ± 43.41 < 0.001 ----- \n \nP val 1: P -value based on comparison between \nEndometriosis and other groups; P val 2: P-value based \non comparison between Diphereline and other groups \nThe surface area of the endometriotic implants, \npathologic and inflammation scoring of the \nendometrial implants are shown in Table 2. \n \nTable 2. Size and pathologic features of the endometrial implants \n Endometrial implants’ size Pathologic score Inflammation score \nGroups Mean ± SD P val 1 P val 2 Mean ± \nSD P val 1 P val 2 Mean ± \nSD P val 1 P val 2 \nEndometriosis 48.33 ± \n5.39 ------ ---- 2.83 ± \n0.40 ------ ---- 2.83 ± \n0.40 ------ ----- \nOlive oil 50.42 ± \n6.90 0.56 < \n0.001 \n2.57 ± \n0.53 0.33 < \n0.001 \n2.57 ± \n0.53 0.34 < \n0.001 \nVitamin D3 19.71 ± \n5.82 < 0.001 0.01 1.28 ± \n0.75 0.001 0.11 1.14 ± \n0.69 \n< \n0.001 0.07 \nOmega3 30.00 ± \n6.20 0.001 0.002 2.20 ± \n0.83 0.13 0.003 2.00 ± \n0.70 0.03 0.001 \nVitaminD3 + \nOmega3 \n15.66 ± \n3.66 < 0.001 0.03 0.66 ± \n0.51 \n< \n0.001 0.99 1.00 ± \n0.63 0.001 0.16 \nDiphereline 12.11 ± \n2.02 < 0.001 ------ 0.66 ± \n0.70 \n< \n0.001 ------ 0.55 ± \n0.52 \n< \n0.001 ----- \n \nThe size of the implants was significantly decreased \nafter the treatment even though diphereline was more \neffective than other ones and there are significant \ndifferences between the current treatments and \ndiphereline ( Figure 1 ) wit h notice to the endometrial \nsize). Specimens of the treated groups stained by \nhematoxylin-eosin (scale bar: 40 μm) are demonstrated \nin Figure 2. \n \n\nZahra Shiravani et al. 502 \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \n \nFigure 2. Specimens of the treated groups stained by hematoxylin-eosin (scale bar: 40 μ m). A) Endometriosis group, B) \nOlive oil group. In A and B, severe cystic endometriosis (the arrow) along with the necrosis and the presence of apoptotic \ncells as well as severe inflammation and the presence of hemosiderin-laden macrophages in different regions was observed. \nC) Vitamin D group, in this group, the severity of inflammation, as well as the necrosis, was reduced. Cystic endometriosis \nwas also slightly decreased compared to the olive oil receiving group. D) Omega 3 group, in this group, cystic endometriosis, \nnecrosis and inflammation were reduced compared to the endometriosis group. However, hemosiderin-laden macrophages \nwere observed in some regions. E) Vitamin D + Omega 3 group, in this group, cystic endometriosis was sharply reduced; \nthe severity of inflammation and necrosis, as well as the presence of apoptotic cells and hemosiderin -laden macrophages, \nwas decreased in different regions. A significant decrease was als o observed in the epithelial layer. F) Diphereline group, \nlike the Vitamin D + Omega 3 group, the severity of cystic endometriosis was reduced in this group. Moreover, a significant \ndecrease was observed in the epithelial layer coverage, inflammation, necrosis, apoptotic cells and hemosiderin -laden \nmacrophages in various regions. \n \nPathologic score indicated a significant reduction in \nvitamin D3, vitamin D3 + omega3 and diphereline . \nInterestingly, the pathologic score in vitaminD3 and \nvitamin D3 + omega3 groups is close to diphereline \ngroup with no significant difference. The inflammation \nscore of the treated group was statistically significant \ndifferences compared to the endometrio sis group. The \nvitaminD3 and vitamin D3 + omega3 groups were not \nsignificantly different compared to the dophereline \ngroup. \n \nDiscussion \nEndometriosis is a common estrogen -dependent \ndisease and is polygenic and multifactorial (31, 32) . \nAlthough estrogen lowering drugs lead to the decrease \nof endometriosis symptoms, they have revealed to \npossess some side effects. New treatments of \nendometriosis include anti -inflammatory drugs, anti -\nangiogenesis agents and statins (33), which lead to the \nreduction of the grow th rate of endometriosis by \ninfluencing angiogenesis, inflammation, and activity of \nmetalloproteinase (34). This investigation aimed to \nevaluate the role of Vitamin -D3 and Omega-3 as anti-\ninflammatory and anti -angiogenetic drugs in the \nimprovement of endom etriosis. As the results of the \npresent study showed, the administration of Vitamin -\nD3 decreased the development of endometriosis which \nmight be attributed to the reduction of inflammation, \nangiogenesis, and prevention of extra -cellular matrix \ndestruction (34). Previous studies demonstrated that \ndysfunction of the immune response such as poor \nactivation of T lymphocytes and natural killer cells, \ndecrease of cytokine secretion by T helper lymphocyte \nand decrease of antibody secretion by B lymphocyte \nare associated with endometriosis (35, 36).  \nIn the present study, TNF α  and IL-6 concentrations \nsignificantly decreased in the Vitamin-D3, Vitamin-D3 \n+ Omega-3 and diphereline receiving groups compared \nto the endometriosis group without treatment. Vitamin-\nD3 is a  strong immune modulator influencing the \ndivision and proliferation of normal and malignant \ncells (12). The Vitamin -D3 receptor and its metab -\nolizing enzymes were found in the endometrium and \nmay act through autocrine and paracrine manner in the \nimmunologic environment (3) . The results of the \npresent study indicated that the pathologic scores \n\n\n503 Effect of Vitamin-D3 and Omega-3 on Endometriosis \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \nsignificantly decreased in the Vitamin -D3 + Omega -3 \nand diphereline groups than in the Omega -3 group. \nFurthermore, a significant decrease was observed in the \ninflammation score of the diphereline group compared \nto the Omega -3 group. Previous studies reported the \nanti-inflammatory, anti -angiogenesis, anti -\nproliferative, and anti-apoptotic roles of Omega-3 (25, \n26). Ruggiero et al. showed that Omega -3 decreased \nthe production of pro- inflammatory cytokines - TNFα, \nIL-1, IL- 6- and prevented the activation of nuclear \nfactor kappa-light-chain-enhancer of activated B cells \n(nuclear factor-κβ).  \nIt is hypothesized that Omega -3 can have a role in \nthe treatment of autoimmunity dysf unctions and \nmalignancies (36). Since endometriosis share some \nsimilarities with systemic inflammation and \nmalignancies in terms of immune impairment, cytokine \ngeneration, and angiogenesis, this agent can be useful \nfor the treatment of endometriosis (12) . Similar to the \nresults of the present study, Tomio, et al. (26)  found \nthat endogen Omega -3 and exogen eicosapentaenoic \nacid have a protective role against peritoneal \nendometriosis (26). Akyol, et al. (10)  showed that \nVitamin-D3 and Omega-3 improved the endometriosis \nby decreasing the endometrial histopathology implants \nvolume and parameters as well as decreasing the IL6, \nTNFα, and VEGF. These results are in agreement with \nthe findings of the current research. Contrary to the \nresults, the decrease in the imp lant volume was  not \nsignificant in the Akyol, et al.  (10) study. It was \nprobably due to the treatment duration which was \nlower than that in the present study (10). In the present \nresearch, the pathologic scores, the inflammation score \nand implant area incr eased in the endometriosis \nwithout treatment and in the endometriosis + olive oil \ngroups compared to the Vitamin -D3, Vitamin -D3 + \nOmega-3 and diphereline receiving groups. Similarly, \nAbbas, et al. (9) reported that peritoneal administration \nof Vitamin-D3 led to the decrease of the implant area \nin rats with endometriosis (9). Gonadotropin -releasing \nhormone agonists such as diphereline cause \ninactivation and degeneration of the endometrial \nimplant through suppression of the hypothalamic -\npituitary-gonad axis (37). Similar to the findings of the \npresent study, Namavar Jahromi, et al.  (28) \ndemonstrated that diphereline decreased the volume \nand area of the endometrial implant and significantly \ndecreased the inflammation and pathologic parameters \ncompared to the control (28). \n \nConclusion \nAs shown by the findings of the current research, the \nco-administration of Omega -3 and Vitamin -D3 was \nmore effective than used alone. This combination acts \nin a manner similar to diphereline. On the other hand, \nadministration of Vitamin -D3 had more favorable \nresults than the Omega -3 treatment for the \nimprovement of endometriosis. According to the \npublic health perspective, more detailed and long-term \nexperimental studies are required to be conducted to \nclarify the association between  Vitamin-D3 and \nOmega-3 with the improvement of endometriosis. This \nwill also give more understanding about the valuable \nproperties of these nutritional agents by identifying the \nalternative treatments for endometriosis. \n \nAcknowledgments \nThis article has b een financially supported by the \nVice Chancellor for Research of Shiraz University of \nMedical Sciences with the grant number of 16092. \nIBFM-CNR thanks for financial support: “Unione \neuropea – Next Generation EU” ID: \nB83C22002930006. \n \nAuthors' Contribution \nZ.S.: Conceptualization, idea, design and writing. \nF.N., M.A., E.A., T.P., N.T., S.R., G.S., N.M., D.P., \nS.S., C.C.: investigation and editing. \n \nConflict of Interest \nThe authors declared that the research was conducted \nin the absence of any commercial or f inancial \nrelationships that could be construed as a potential \nconflict of interest. \n \nEthical Approval \nThis study was approved by the Medical Ethics \nCommittee of Shiraz University of Medical Sciences \n(IR.SUMS.MED.REC.1398.032). \n \n \n1. 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[PMID]  \n[DOI:10.1111/j.1600-0897.2010.00887.x]  \n36. Ruggiero C, Lattanzio F, Lauretani F, Gasperini \nB, Andres -Lacueva C, Cherubini A. Omega -3 \npolyunsaturated fatty acids and immune -\nmediated diseases: inflammatory bowel disease \nand rheumatoid arthritis. Curr Pharm Des. 2009;  \n15(36):4135-48. \n[DOI:10.2174/138161209789909746] [PMID] \n37. Vercellini P, Somigliana E, Vigano P, Abbiati A, \nBarbara G, Crosignani PG. Endometriosis: \ncurrent therapies and new pharmacologi cal \ndevelopments. Drugs. 2009;69(6):649-75.  \n[DOI:10.2165/00003495-200969060-00002] \n[PMID]\n \n \n \n \n \n\nZahra Shiravani et al. 506 \n      Volume 9, September – October 2024       Journal of Obstetrics, Gynecology and Cancer Research \n \n \n \nHow to Cite This Article:  \nShiravani, Z., Najib, F., Alirahimi, M., Askary, E., Poordast, T., Tanideh, N., et al. The Supplemental Effect of \nVitamin-D3 and Omega -3 on Induced Endometriosis in Rat Model to Investigate the Inflammatory Response . J \nObstet Gynecol Cancer Res. 2024;9(5):498-506. \nDownload citation:                             RIS | EndNote | Mendeley |BibTeX |","source_license":"CC0","license_restricted":false}