GDF9 and endometriosis: Subsequently, cytoplasmic ATP signaling gradually decreased, which was accompanied by an increase in the number of dead cells.15The fact that cumulus cells naturally proliferate throughout the process of folliculogenesis under the influence of FSH, estradiol,19and growth factors generated by oocytes supports this explanation even more (GDF9, BMP15).20In a study by Hendarto et al.,4it was discovered that patients with endometriosis had lower levels of GDF-9 in their follicular fluid.