CD11c+ M1-like macrophages (MΦs) but not CD206+ M2-like MΦ are involved in folliculogenesis in mice ovary.

Macrophages (MΦs) are involved in folliculogenesis and ovulation. However, it is unknown which type of MΦ, M1 or M2, plays a more essential role in the ovary. CD206 or CD11c diphtheria toxin receptor transgenic (DTR) mice, which enable depletion of CD206+ M2 MΦs and CD11c+ MΦ or CD11c+ Dendritic cells (DCs), respectively, were used. Oocytes were used for in vitro fertilization and embryo transfer. In vitro fertilized embryos derived from M2 MΦ depleted oocytes were transferred to pseudo pregnant wild type mice. CD11c DTR mice were also used to investigate the role of CD11c cells, M1 MΦ and DCs in folliculogenesis. In WT mice, the proportion of CD206+ M2-like MΦs was not increased in follicular induction, while that of CD11c+ M1-like MΦs was increased. In CD206 DTR mice, folliculogenesis was normal and the ovulation number, fertilization rate, and implantation rate were similar to those in WT mice. In CD11c DTR mice, folliculogenesis was impaired with ovarian hemorrhage and the staining of platelet derived growth factor-receptor ß (PDGF-Rß), a marker of pericytes, and CD34, a marker of endothelial cells, was reduced. CD11c+ cells, M1 MΦs or DCs, may be involved in folliculogenesis, while M2 MΦs are not involved in folliculogenesis.

Oil-Soluble Contrast Medium (OSCM) for Hysterosalpingography Modulates Dendritic Cell and Regulatory T Cell Profiles in the Peritoneal Cavity: A Possible Mechanism by Which OSCM Enhances Fertility.

Hysterosalpingography (HSG) with oil-soluble contrast medium (OSCM) is known to enhance fertility, although the mechanism is unclear. OSCM remains in the peritoneal cavity for several months after HSG. We hypothesized that OSCM that remains in the peritoneal cavity modulates dendritic cell (DC) and regulatory T cell (Treg) profiles and contributes to enhanced fertility. We characterized the profiles of DCs and Tregs in the peritoneal fluid from women who had undergone HSG. In vitro and in vivo effects of OSCM on monocyte-derived DCs and mouse peritoneal T cells were also evaluated. In comparison with women who have never experienced HSG, samples from women who had undergone HSG contained myeloid DCs with greater complexity and maturation, as well as had a marginally greater proportion of Tregs in their peritoneal fluid. OSCM is incorporated by monocyte-derived DCs, which causes their maturation and contributes to the increase in Treg proportions. Samples from OSCM-injected mice contained greater proportions of Tregs in comparison with controls. These studies demonstrate that OSCM modulates T cell profiles that are compatible with the condition observed in women who have undergone HSG. This study demonstrates that exogenous lipids administered to the peritoneal cavity are incorporated by DCs and that they significantly alter the immune environment in the peritoneal cavity. This immunological impact may contribute to enhanced fertility and the development of alternative therapeutic strategies for managing other pathological conditions associated with immunological abnormalities in the peritoneal cavity.

Mannose receptor is highly expressed by peritoneal dendritic cells in endometriosis.

OBJECTIVES: To characterize peritoneal dendritic cells (DCs) in endometriosis and to clarify their role in its etiology. DESIGN: Experimental. SETTING: University hospital. PATIENT(S): Sixty-three women (35 patients with endometriosis and 28 control women) who had undergone laparoscopic surgery. INTERVENTION(S): Peritoneal DCs from endometriosis and control samples were analyzed for the expression of cell surface markers. Monocyte-derived dendritic cells (Mo-DCs) were cultured with dead endometrial stromal cells (dESCs) to investigate changes in phagocytic activity and cytokine expression. MAIN OUTCOME MEASURE(S): Cell surface markers and cytokine expression and identification with the use of flow cytometry or reverse-transcription polymerase chain reaction (RT-PCR). Changes in cytokine expression and phagocytic activity of Mo-DCs cultured with dESCs and d-mannan were measured with the use of flow cytometry and RT-PCR. RESULT(S): The proportion of mannose receptor (MR)-positive myeloid DC type 1 was higher in endometriosis samples than in control samples. The blocking of MR reduced phagocytosis of dESCs by Mo-DCs. Mo-DCs cultured with dESCs expressed higher levels of interleukin (IL) 1ß and IL-6 than control samples. CONCLUSION(S): Peritoneal DCs in endometriosis tissue express high levels of MR, which promotes phagocytosis of dead endometrial cells and thereby contributes to the etiology of endometriosis.

Disagreement between fourth generation FloTrac and LiDCOrapid measurements of cardiac output and stroke volume variation during laparoscopic colectomy.

STUDY OBJECTIVE: To determine the agreement between cardiac output (CO) and stroke volume variation (SVV) measured simultaneously by the fourth generation FloTrac/Vigileo system and LiDCOrapid system during pneumoperitoneum in patients undergoing laparoscopic colectomy. DESIGN: Retrospective observational study. SETTINGS: Operating room in a general hospital. PATIENTS: Ten patients (American Society of Anesthesiologist 1 or 2) without preoperative anemia. INTERVENTIONS: A 22-gauge catheter was inserted in the radial artery after induction of anesthesia. The arterial line was split to monitor CO and SVV simultaneously with the LiDCOrapid and fourth generation FloTrac/Vigileo systems. All data were downloaded from each system after surgery and simultaneous paired COFloTrac, COLiDCO and SVVFloTrac, SVVLiDCO values estimated every 1 minute during the pneumoperitoneum were analyzed. MEASUREMENTS: To assess the agreement after carbon dioxide insufflation, a scatter 4-quadrant plot was generated using paired ΔCO values (changes in COFloTrac and COLiDCO just before pneumoperitoneum and 3 minutes after the induction of pneumoperitoneum). For data in which SVVFloTrac was >9% but <16% and cardiac index measured by FloTrac/Vigileo was <2.5 L/min per m2 during stable pneumoperitoneum (the period from 5 minutes after Trendelenburg position until discontinuation of pneumoperitoneum), simultaneously measured paired SVVFloTrac and SVVLiDCO were plotted every 1 minute using the Bland-Altman method. MAIN RESULTS: A concordance ratio for changes in CO after the induction of pneumoperitoneum was 83% in 4-quadrant plot. During stable pneumoperitoneum, 702 paired SVVFloTrac and SVVLiDCO matched the criteria. These data sets were plotted by the Bland-Altman method and the bias and 95% limit of agreement of SVV were 2.01 and -2.63% to 6.65%, respectively, with 38% percentage error. The regression equation was SVVLiDCO = 0.98 × SVVFloTrac- 1.73 with Pearson correlation coefficient of 0.55. CONCLUSIONS: Our study showed disagreement between the 2 methods and the hemodynamic parameters measured by one of the two devices should be interpreted with caution before therapeutic interventions.

Neutrophil depletion reduces endometriotic lesion formation in mice.

PROBLEM: Neutrophils are known to be accumulated in endometriosis; however, direct evidence of the impact of neutrophils in the development of endometriosis was lacking. To clarify the importance of neutrophils, we examined the effect of neutrophil depletion on the development of endometriosis. METHOD OF STUDY: Ovariectomized, estradiol-replaced, 8-week-old, female BALB/c mice were injected with endometrial fragments (Day 0). Neutrophils were depleted by anti-Gr-1 antibody, either in the early stage (from Day 1 to Day 3, group E) or late stage (from Day 8 to Day 12, group L). Control mice (group C) did not receive antibodies. On Day 14, mice were killed and the number and weight of endometriotic lesions were counted and weighed. RESULTS: The number of endometriotic lesions was significantly less in group E in comparison with Group C and Group L. Weight per lesion did not differ between groups. CONCLUSION: Neutrophils are essential for the initial formation of endometriosis.

Effects of 1,25-Dihydroxy Vitamin D3 on Endometriosis.

CONTEXT: Endometriosis is an estrogen-dependent, chronic inflammatory disease. Recent studies have shown that vitamin D (VD) is an effective modulator of the immune system and plays an important role in controlling many inflammatory diseases. OBJECTIVE: The objective of the study was to clarify the in vitro effects of 1,25-dihydroxy vitamin D3 (1,25[OH]2D3) on human endometriotic stromal cells (ESCs) and to determine the serum levels of VD in endometriosis patients. DESIGN, PATIENTS, AND MAIN OUTCOME MEASURES: ESCs were isolated from ovarian endometrioma and cultured with 1,25(OH)2D3. Gene expression of IL-8, cyclooxygenase-2, microsomal prostaglandin E synthase-1, microsomal prostaglandin E synthase-2, cytosolic prostaglandin E synthase, 15-hydroxyprostaglandin dehydrogenase, matrix metalloproteinase (MMP)-2, and MMP-9 was examined using quantitative RT-PCR. The production of IL-8 and prostaglandin E2 was measured using an ELISA and an enzyme immunoassay. Viable cell number was assessed using a cell-counting assay, and DNA synthesis was assessed using the bromodeoxyuridine incorporation assay. Apoptosis was assessed using flow cytometry. The expression of inhibitory-κBα protein was detected using Western blotting. The serum levels of 25-hydroxyvitamin D3 and 1,25(OH)2D3 were measured by a RIA. RESULTS: In vitro studies showed that 1,25(OH)2D3 significantly reduced IL-1ß- or TNF-α-induced inflammatory responses, such as IL-8 expression and prostaglandin activity. 1,25(OH)2D3 also reduced viable ESC numbers and DNA synthesis but did not affect apoptosis. MMP-2 and MMP-9 expressions were reduced by 1,25(OH)2D3. 1,25(OH)2D3 inhibited nuclear factor-κB activation. The serum 25-hydroxyvitamin D3 levels were significantly lower in women with severe endometriosis than in the controls and women with mild endometriosis. Serum 1,25(OH)2D3 levels were not different between groups. CONCLUSIONS: VD modulates inflammation and proliferation in endometriotic cells, and a lower VD status is associated with endometriosis. Taken together, VD supplementation could be a novel therapeutic strategy for managing endometriosis.

Interleukin-11 alters placentation and causes preeclampsia features in mice.

Preeclampsia (PE) is a pregnancy-specific disorder characterized by hypertension and proteinuria after 20 wk gestation. Abnormal extravillous trophoblast (EVT) invasion and remodeling of uterine spiral arterioles is thought to contribute to PE development. Interleukin-11 (IL11) impedes human EVT invasion in vitro and is elevated in PE decidua in women. We demonstrate that IL11 administered to mice causes development of PE features. Immunohistochemistry shows IL11 compromises trophoblast invasion, spiral artery remodeling, and placentation, leading to increased systolic blood pressure (SBP), proteinuria, and intrauterine growth restriction, although nonpregnant mice were unaffected. Real-time PCR array analysis identified pregnancy-associated plasma protein A2 (PAPPA2), associated with PE in women, as an IL11 regulated target. IL11 increased PAPPA2 serum and placental tissue levels in mice. In vitro, IL11 compromised primary human EVT invasion, whereas siRNA knockdown of PAPPA2 alleviated the effect. Genes regulating uterine natural killer (uNK) recruitment and differentiation were down-regulated and uNK cells were reduced after IL11 treatment in mice. IL11 withdrawal in mice at onset of PE features reduced SBP and proteinuria to control levels and alleviated placental labyrinth defects. In women, placental IL11 immunostaining levels increased in PE pregnancies and in serum collected from women before development of early-onset PE, shown by ELISA. These results indicate that elevated IL11 levels result in physiological changes at the maternal-fetal interface, contribute to abnormal placentation, and lead to the development of PE. Targeting placental IL11 may provide a new treatment option for PE.

[Acute Ventilatory Failure during Prone Thoracoscopic Esophagectomy with Carbon Dioxide Insufflation in a Patient Managed by a Single Lumen Tracheal Tube].

A 67-year-old woman underwent prone thoracoscopic esophagectomy with carbon dioxide (CO2) insufflation. After insertion of an epidural catheter, general anesthesia was induced with propofol, sevoflurane, remifentanil and rocuronium. The trachea was intubated with a single lumen endotracheal tube (SLET). CO2 insufflation at 5 mmHg with the SLET deflated the right lung and provided excellent visualization without respiratory instability. The left side pleura was injured during the inferior mediastinal lymphadenectomy and the patient went into sudden profound hypoventilation with an increase in end-tidal CO2 from 43 to 64 mmHg. We observed the trachea with bronchofiberscope and the SLET was correctly located and not obstructed. We were convinced that bilateral pneumothorax occurred because the left side pleura was injured and auscultation revealed decreased breath sounds over the left hemithorax. We asked the surgeon to discontinue the insufflated CO2 and both lungs were fully expanded. The operation was then carried out successfully without further untoward event. The patient was successfully extubated at the intensive care unit on postoperative day 1. The CO2 insufflation during thoracoscopic esophagectomy can cause bilateral pneumothorax and we recommend to inflate the bilateral lungs regularly for the continuation of the surgery.

[Strategy for Determining the Appropriate Dose of Sugammadex with Monitoring Train-of-four (TOF) Responses at the End of Surgery].

BACKGROUND: Intraoperative monitoring of train-of-four (TOF) response is recommended to avoid inadequate dose of muscle relaxant and its antagonist. We have standardized monitoring of TOF response at the end of surgery in all the patients undergoing general anesthesia with rocuronium since October 2013. METHODS: TOF group comprised of 113 consecutive patients just after the standardization and we investigated the relationship between the dose of sugammadex and TOF count and also compared anesthetic factors in TOF group with those in control group which included 104 consecutive patients just before the standardization without TOF monitoring. RESULTS: Rate of the patients with TOF count 4 in TOF group approximately reached 70% and mean TOF ratio resulted in 0.56 ± 0.28. Mean dose of sugammadex in patients with TOF count 2-4 was 2.5 ± 0.9 mg x kg(-1), while the dose in patients with TOF count 0-1 was 3.6 ± 0.9 mg x kg(-1) and 6 patients among 11 patients with TOF count 0 was given less than 4 mg x kg(-1) of sugammadex. The percentage of the patients given 200 mg of sugammadex significantly decreased from 78% in control group to 48% in TOF group. CONCLUSIONS: We conclude that standardization of TOF response at the end of surgery reduces dose of sugammadex in patients with slight residual neuromuscular block though the dose in patients under deep muscle relaxation seems to be insufficient.

Cyclic stretch augments production of neutrophil chemokines, matrix metalloproteinases, and activin a in human endometrial stromal cells.

PROBLEM: The aim of this study was to test our hypothesis: Contractile activity that occurs in the uterus during menstruation induces biochemical factors that enhance remodeling of the endometrium. METHOD OF STUDY: Cyclic stretch, mimicking contractile activity during menstruation, was applied to human endometrial stromal cells (ESC) using the Flexercell Tension system. The concentration and activity of CXCL8, CXCL1, MMPs, and activin A were measured using ELISAs and specific assays. Neutrophil chemotactic activity was evaluated using migration assays. RESULTS: Cyclic stretch significantly induced ESC secretion of CXCL8 and CXCL1 and neutrophil chemotaxis. Stretch also increased MMP-1, MMP-2, and MMP-3 activity, activin A secretion, and activity in ESC. CONCLUSION: These results indicate that the contractile activities of the uterus during menstruation contribute to the remodeling of the endometrium, by inducing chemokine secretion, MMP expression, activity, and neutrophil chemotaxis.

IL-1ß increases expression of tryptophan 2,3-dioxygenase and stimulates tryptophan catabolism in endometrioma stromal cells.

PROBLEM: Immune tolerance to endometriotic cells is important to promote endometriosis. Tryptophan 2,3-dioxygenase (TDO) enhances immune tolerance by catabolizing tryptophan to kynurenine. We studied whether interleukin-1ß (IL-1ß), a typical endometriosis-associated cytokine, affects the expression of TDO and the catabolism of tryptophan in endometrioma stromal cells (ESCs). We also studied whether the expression of TDO is involved in IL-1ß-induced secretion of IL-6 and IL-8 in ESCs. METHOD OF STUDY: Nineteen endometriotic patients of reproductive age with normal menstrual cycles were recruited. Primary cultures of ESCs were treated with IL-1ß and TDO siRNA. TDO mRNA was measured using quantitative PCR. TDO protein was measured using Western blotting. Concentrations of kynurenine in condition media were measured using Ehrlich reagent. Concentrations of tryptophan in conditioned media were measured using tryptophan detection kit. Concentrations of IL-6 and IL-8 in conditioned media were measured using ELISA kits. RESULTS: IL-1ß (1 ng/mL) increased the expression of TDO mRNA and TDO protein in ESCs. IL-1ß-treated ESCs increased the production of kynurenine and the effect was inhibited by TDO siRNA. Treatment with the siRNA also decreased IL-1ß-induced secretion of IL-6 and IL-8 from ESCs. CONCLUSION: IL-1ß is suggested to stimulate tryptophan catabolism and production of IL-6 and IL-8 by increasing TDO expression in endometriosis.

Dienogest reduces proliferation, aromatase expression and angiogenesis, and increases apoptosis in human endometriosis.

Dienogest is a novel progestin that is highly selective for progesterone receptors and inhibits endometriosis. However, it remains unknown how the administration of dienogest to patients with endometriosis impacts on their lesion tissues. The aim of this study was to evaluate the in vivo effect of dienogest on endometriosis tissue. We collected endometrioma tissues from patients treated with dienogest (N = 7) or not treated (N = 11, controls). Cell proliferation, aromatase expression and blood vessel density were evaluated by staining for Ki67, aromatase and the von Willebrand factor, respectively. Apoptosis was detected using the TUNEL assay. The proportion of Ki67 and aromatase positive epithelial cells was significantly lower in the dienogest group than in controls (p < 0.05, respectively). The number of TUNEL positive cells was significantly higher in the dienogest group (p < 0.05). The density of blood vessels in endometrioma was marginally lower in the dienogest group compared with controls (p = 0.20). Our study demonstrates that endometrioma taken from patients treated with dienogest show remarkable histological features such as reduction of proliferation, aromatase expression and angiogenesis, and increase of apoptosis. This study clarified the impact of dienogest on local histological events that explain its therapeutic effect on endometriosis.

Interleukin-4 and prostaglandin E2 synergistically up-regulate 3ß-hydroxysteroid dehydrogenase type 2 in endometrioma stromal cells.

CONTEXT: Endometriosis is a chronic inflammatory disease in which immune response and production of estrogen in endometriotic tissues are involved in the development of the disease. Prostaglandin E2 (PGE2) stimulates aromatase (P450arom) expression in endometrioma stromal cells (ESCs) and increases the production of estrogens. On the other hand, an accumulating amount of evidence suggests that IL-4, a typical Th2 cytokine, plays important roles in the disease. OBJECTIVE: The objective of the investigation was to study the effect of IL-4 on the expression of 3ß-hydroxysteroid dehydrogenase (HSD3B2), a pivotal enzyme for estrogen production, in ESCs. DESIGN, PATIENTS, AND MAIN OUTCOME MEASURES: ESCs were isolated from ovarian endometrioma tissues and cultured with IL-4 and PGE2. CP-690550, a Janus protein tyrosine kinase 3 inhibitor, and HSD3B2 small interfering RNA were added to the culture. Gene expression of HSD3B2 and P450arom was examined by quantitative RT-PCR. Dehydroepiandrosterone (DHEA) was added to the culture, and then the combined enzyme activity of HSD3B2, which converts DHEA to androstenedione, and P450arom, which converts androstenedione to estrone, was examined by measuring estrone concentration in the supernatants with a specific enzyme immunoassay. RESULTS: IL-4 increased the expression of HSD3B2 mRNA in a dose-dependent manner. CP-650550 inhibited the IL-4-induced increase in HSD3B2 mRNA expression. PGE2 also increased the expression of HSD3B2 mRNA, and the combination of IL-4 and PGE2 synergistically increased the expression of HSD3B2 mRNA. IL-4 had no effect on the expression of P450arom mRNA, whereas PGE2 increased the expression of P450arom mRNA. Although PGE2 alone increased the production of estrone from DHEA, the combination of IL-4 and PGE2 significantly augmented the production of estrone from DHEA. The enhanced production of estrone by the combination of IL-4 and PGE2 was inhibited by CP-690550 and HSD3B2 small interfering RNA. CONCLUSIONS: IL-4 in combination with PGE2 may enhance estrogen production in endometriotic tissues, implying an elaborate mechanism that Th2 immune response augments inflammation-dependent progression of the disease.

Interleukin-1ß stimulates the secretion of thymic stromal lymphopoietin (TSLP) from endometrioma stromal cells: possible involvement of TSLP in endometriosis.

STUDY QUESTION: Is thymic stromal lymphopoietin (TSLP) involved in the pathophysiology of endometriosis? SUMMARY ANSWER: TSLP is up-regulated by interleukin (IL)-1ß and may be involved in the development of endometriosis. WHAT IS KNOWN ALREADY: Endometriosis is a chronic inflammatory disease in which the Th2 immune response is activated and has been suggested to promote the disease. TSLP is a master cytokine that drive Th2 immune response. STUDY DESIGN, SIZE, DURATION: A laboratory study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Primary cultures of endometrioma stromal cells (ESCs) were treated with IL-1ß, a typical inflammatory cytokine associated with endometriosis. Gene expression of TSLP in ESCs and secretion of TSLP protein from ESCs were studied using quantitative PCR and a specific ELISA. Interferon γ (IFNγ), a typical Th1 cytokine, and IL-4, a typical Th2 cytokine, were added to the culture to evaluate their effect on the IL-1ß-induced secretion of TSLP. Inhibitors of p38 mitogen-activated protein kinase (MAPK), p42/44 MAPK and stress-activated protein kinase/Jun amino-terminal kinase (SAPK/JNK) were added to the culture to examine intracellular signals involved in IL-1ß-induced TSLP secretion. The expression of TSLP in endometrioma tissue was examined by immunohistochemistry. The concentration of TSLP in the serum and peritoneal fluid (PF) of women with or without endometriosis was measured with a specific ELISA. MAIN RESULTS AND THE ROLE OF CHANCE: IL-1ß stimulated the expression of TSLP mRNA and secretion of TSLP protein from ESCs. IL-4 enhanced the IL-1ß-induced TSLP secretion from ESCs, while IFNγ reduced it. Inhibitors of p42/44 MAPK, p38 MAPK and SAPK/JNK suppressed the IL-1ß-induced secretion of TSLP from ESCs. Positive immunostaining of TSLP was observed in the stroma of endometrioma tissue. TSLP concentrations in the serum and PF were both higher in women with endometriosis compared with those without endometriosis. LIMITATIONS, REASONS FOR CAUTION: The present study was only in vitro. The samples used for culture were endometrioma tissues, not including other types of endometriosis. Therefore, the present findings should be interpreted with caution. WIDER IMPLICATIONS OF THE FINDINGS: This study provided new insights in the Th2 immune response-related mechanism in endometriosis. STUDY FUNDING: This study is partly supported by grants from the Ministry of Health, Labour and Welfare, and the Ministry of Education, Culture, Sports, Science and Technology. The authors have no conflicts of interest to declare.

Thrombin enhances soluble Fms-like tyrosine kinase 1 expression in trophoblasts; possible involvement in the pathogenesis of preeclampsia.

OBJECTIVE: To investigate the possible impact of thrombin on soluble Fms-like tyrosine kinase 1 (sFlt-1) expression in trophoblasts. DESIGN: Experimental. SETTING: University hospital laboratory. INTERVENTIONS(S): A trophoblast cell line (HRT-8/SVneo) was treated with thrombin, protease-activated receptor 1 (PAR-1)-specific agonist SFLLERN, and thrombin antagonist PPACK. MAIN OUTCOME MEASURE(S): mRNA expression of sFlt-1, vascular endothelial growth factor (VEGF), and placental growth factor (PlGF) in trophoblasts, with the use of real-time polymerase chain reaction; and the secretion of sFlt-1, VEGF, and PlGF protein from trophoblasts, with the use of ELISA. RESULT(S): Administration of thrombin (10 U/mL) and PAR-1-specific agonist SFLLRN (300 µmol/L) increased sFlt-1 mRNA expression (4.24 ± 0.74- and 4.21 ± 0.79-fold, respectively) and protein secretion (5.08 ± 0.42- and 1.89 ± 0.16-fold, respectively) in HRT-8/SVneo. The induction of sFlt-1 protein secretion by thrombin was dose dependent. The effect of thrombin was completely reduced by thrombin inhibitor PPACK. Thrombin increased mRNA expression of VEGF but did not change VEGF secretion and PlGF mRNA expression and secretion. CONCLUSION(S): During placental development, thrombin, generated in the local hemorrhage of the uteroplacenta increases trophoblast expression of sFlt-1. Consequently, thrombin may contribute to the pathogenesis of preeclampsia.

Autoamputated adnexa presents as a peritoneal loose body.

We report a case of unilateral adnexal absence with a peritoneal loose body. Laparoscopic findings and medical history suggested that she had adnexal torsion in her childhood followed by its calcification and autoamputation.