Evaluating Chronic Endometritis in Women with Recurrent Implantation Failure and Recurrent Pregnancy Loss by Hysteroscopy and Immunohistochemistry

Correlation of hysteroscopic findings of chronic endometritis with CD138 immunohistochemistry and their correlation with pregnancy outcomes

PURPOSE

To investigate the correlation between hysteroscopic findings of chronic endometritis and CD138 immunohistochemistry positive in endometritis and to analyze the pregnancy outcomes and associated risk factors following embryo transfer in women diagnosed with chronic endometritis via hysteroscopy.

METHODS

A retrospective observational study carried out at the Reproductive Medicine Center of Tangdu Hospital of Air Force Medical University, from January 2021 to December 2021, was performed by obtaining data from 194 medical records of women who underwent hysteroscopies for infertility and were diagnosed with chronic endometritis based on Delphi criteria. Spearman correlation analysis was used to evaluate the correlation between hysteroscopic findings and endometrial CD138 immunohistochemistry. The study also observed the differences in relevant indexes between the CD138-positive and CD138-negative groups after embryo transfer and analyzed factors influencing implantation failure using logistic regression analysis.

RESULTS

The correlation analysis between hysteroscopic findings and CD138 immunohistochemistry showed that micropolyps were correlated with CD138 immunohistochemistry positivity. The correlation coefficient was 0.32 (P < 0.01). After embryo transfer, the clinical pregnancy rate of the CD138-positive group was lower compared to that of the CD138-negative group [64.79% (46/71) vs. 81.30% (100/123), P < 0.05]. The results of the multivariate logistic regression analysis revealed that age (P = 0.43) and CD138 immunohistochemistry positivity (P = 0.008) were the independent risk factors for predicting whether or not embryo implantation was successful.

CONCLUSION

Hysteroscopic findings do not correlate strongly with endometrial CD138 immunohistochemistry, and chronic endometritis cannot be diagnosed by hysteroscopy alone. CD138 immunohistochemistry positivity is an independent factor contributing to the decrease in clinical pregnancy rate following embryo transfer.

Risk factors of chronic endometritis in women who have undergone hysteroscopy: a prospective nested case-control study

There is limited research on risk factors for chronic endometritis regarding reproductive history and clinical symptoms. Thus, this nested case-control study identified risk factors for chronic endometritis in women who have undergone hysteroscopy. Endometrial tissue sections were obtained from 502 women with intrauterine disorders who underwent hysteroscopy. Chronic endometritis was diagnosed via CD138 immunostaining. The women were divided into two groups: 271 women without chronic endometritis and 231 women with chronic endometritis. The prevalence of chronic endometritis was 46%. Univariate logistic regression revealed that prolonged menstruation and intermenstrual bleeding were associated with chronic endometritis, and subsequent multivariate logistic regression analyses showed that these were further independently associated. With univariable logistic regression, the gravidity and abortion history were correlated with chronic endometritis; however, no significant correlation was found with the adjusted odds ratio (OR) of 0.74 (95% confidence interval [CI] 0.46-1.19) or 0.76 (95% CI 0.58-1.11), respectively. No significant correlation was found between caesarean section history and the rates of chronic endometritis. No significant difference was found in all other variables between the three groups with > 5, ≤ 5 plasma cells and in a unknown group. Prolonged menstruation and intermenstrual bleeding were risk factors associated with chronic endometritis. Chronic endometritis should be considered and CD138 immunohistochemical examination should be recommended in women with these symptoms.

Antibiotics improve reproductive outcomes after frozen-thaw embryo transfer for chronic endometritis treatment, especially in those with repeated implantation failure

PURPOSE

To investigate the impact of antibiotic treatment for chronic endometritis (CE) on the pregnancy outcome of frozen-thawed embryo transfer (FET) cycles and the relevant clinical risk factors associated with CE.

METHODS

A retrospective cohort analysis was conducted on 1352 patients who underwent hysteroscopy and diagnostic curettage at Nanjing Maternal and Child Health Hospital from July 2020 to December 2021. All patients underwent CD138 immunohistochemical (IHC) testing to diagnose CE, and a subset of them underwent FET after hysteroscopy. Patient histories were collected, and reproductive prognosis was followed up.

RESULTS

Out of 1088 patients, 443 (40.7%) were diagnosed with CE. Univariate and multivariate binary logistic regression analyses revealed that parity ≥ 2, a history of ectopic pregnancy, moderate-to-severe dysmenorrhea, hydrosalpinx, endometrial polyps, a history of ≥ 2 uterine operations, and RIF were significantly associated with an elevated risk of CE (P < 0.05). Analysis of the effect of CE on pregnancy outcomes in FET cycles after antibiotic treatment indicated that treated CE patients exhibited a significantly lower miscarriage rate (8.7%) and early miscarriage rate (2.9%) than untreated non-CE patients (20.2%, 16.8%). Moreover, the singleton live birth rate (45.5%) was significantly higher in treated CE patients than in untreated non-CE patients (32.7%). Survival analysis revealed a statistically significant difference in the first clinical pregnancy time between treated CE and untreated non-CE patients after hysteroscopy (P = 0.0019). Stratified analysis based on the presence of recurrent implantation failure (RIF) demonstrated that in the RIF group, treated CE patients were more likely to achieve clinical pregnancy than untreated non-CE patients (P = 0.0021). Among hysteroscopy-positive patients, no significant difference was noted in pregnancy outcomes between the treatment and control groups (P > 0.05).

CONCLUSION

Infertile patients with a history of parity ≥ 2, hydrosalpinx, a history of ectopic pregnancy, moderate-to-severe dysmenorrhea, endometrial polyps, a history of ≥ 2 uterine operations, and RIF are at an increased risk of CE; these patients should be recommended to undergo hysteroscopy combined with CD138 examination before embryo transfer. Antibiotic treatment can improve the reproductive outcomes of FET in patients with CE, especially those with RIF.

Bridging the Diagnostic Gap between Histopathologic and Hysteroscopic Chronic Endometritis with Deep Learning Models

Chronic endometritis (CE) is an inflammatory pathologic condition of the uterine mucosa characterized by unusual infiltration of CD138(+) endometrial stromal plasmacytes (ESPCs). CE is often identified in infertile women with unexplained etiology, tubal factors, endometriosis, repeated implantation failure, and recurrent pregnancy loss. Diagnosis of CE has traditionally relied on endometrial biopsy and histopathologic/immunohistochemistrical detection of ESPCs. Endometrial biopsy, however, is a somewhat painful procedure for the subjects and does not allow us to grasp the whole picture of this mucosal tissue. Meanwhile, fluid hysteroscopy has been recently adopted as a less-invasive diagnostic modality for CE. We launched the ARCHIPELAGO (ARChival Hysteroscopic Image-based Prediction for histopathologic chronic Endometritis in infertile women using deep LeArninG mOdel) study to construct the hysteroscopic CE finding-based prediction tools for histopathologic CE. The development of these deep learning-based novel models and computer-aided detection/diagnosis systems potentially benefits infertile women suffering from this elusive disease.

Prevalence and confounders of chronic endometritis diagnosed using CD138 in patients with recurrent implantation failure

OBJECTIVE

This retrospective study aimed to investigate the prevalence of chronic endometritis, diagnosed using CD138 immunohistochemistry, among infertile women and to assess the association between chronic endometritis and recurrent implantation failure (RIF).

METHODS

In total, 266 patients who underwent hysteroscopy due to infertility between 2019 and 2020 were included in the analysis. Of these, 136 patients with RIF and 130 non-RIF patients were included in the study. CD138 immunohistochemistry test results, blood biomarkers (including natural killer cells, white blood cells, and the lymphocyte-to-neutrophil ratio), and data on pregnancy outcomes were obtained. If the CD138 test yielded a positive result, the patients received antibiotic treatment.

RESULTS

The overall proportion of CD138-positive patients was 32.7% (87/266). The CD138 positivity rate was not related to the number of cycles with implantation failure. In the RIF patient group, no significant associations were found between CD138 positivity and peripheral blood markers. The clinical pregnancy rates were similar between infertile women treated with antibiotics for chronic endometritis and those without chronic endometritis.

CONCLUSION

To improve the pregnancy rate in infertile patients, it may be helpful to combine CD138 testing with other laboratory tests and administer antibiotic treatment if the result is positive.

Correlation between hysteroscopic features and specific microbial species in women with chronic endometritis

Objective and rationale

Chronic endometritis (CE) has recently been associated with unexplained infertility and recurrent miscarriages. The current gold standard for CE detection is histopathological examination. However, office hysteroscopy and endometrial cultures are also significant, due to the possible link between CE and various microorganisms. Bacterial colonization of the endometrium has been associated with reduced success rates of in vitro fertilisation embryo transfer. Few studies have tried to correlate CE hysteroscopy findings with pathogenic microorganisms. This prospective cohort study sought to establish whether hysteroscopic diagnostic lesions correlate with specific microbial species.

Methods

The study encompassed women undergoing diagnostic tests for a range of subfertility health issues. 189 women completed the standard office diagnostic hysteroscopy (DH). 181 had also endometrial samples taken for microbial culture investigation. Correlation analysis (χ2 and Fisher's exact test) between hysteroscopic findings suggestive of CE and endometrial cultures was carried out. Logistic regression models were also fitted to measure whether a positive endometrial culture could affect CE conditions.

Results

A significant association of E. coli was observed between the hysteroscopically characterized CE + group with focal hyperplasia, when compared to the non-CE group. Logistic regression analysis revealed that women positive for E. coli were 4.423 times more likely to have focal endometrial hyperplasia. No other significant correlations were identified between DH and positive endometrial cultures.

Conclusions

The presence of E. coli in the endometrium was significantly correlated with focal hyperplasia findings from hysteroscopy, emphasizing the importance of microbial cultures in the diagnosis and targeted treatment of CE in women with subfertility.

Association of Y chromosome AZF region microdeletions with recurrent miscarriage in Iranian couples: A case-control study

BACKGROUND

Recent studies have linked recurrent pregnancy loss (RPL) to abnormalities in the sperm genome, specifically microdeletions in the azoospermia factor (AZF) region. This study investigated the potential association between Y chromosome microdeletions in the AZF region and RPL in Iranian couples.

METHODS

The research presents a case-control study of 240 men: 120 whose partners experienced recurrent miscarriage, and 120 who had successful pregnancies without history of miscarriage. The study used semen parameters, hormone analyses, and microdeletion analysis via multiplex PCR and the YChromStrip kit. Thus, the sequence-tagged site (STS) markers of AZFa (sY84, sY86), AZFb (sY127, sY134), and AZFc (sY254, sY255) regions were examined.

RESULTS

The variations in semen parameters and sex hormone levels between cases and controls are suggest impaired testicular function in men whose partners had recurrent miscarriages (p < 0.05). Furthermore, the study revealed a negative correlation between sperm count and follicle-stimulating hormone (FSH) level, and a positive one between sperm motility and testosterone concentration. There were no microdeletions in the control group, while the RPL group showed 20 deletions in AZFb (sY134) (16.66%) and 10 deletions each in AZFb (sY127) (8.33%) and AZFc (sY254) (8.33%).

CONCLUSION

Microdeletions in sY134 (AZFb) were significantly associated with RPL in Iranian men (p = 0.03). AZF microdeletion screening in couples with RPL can provide valuable information for ethnical genetic counseling and management of recurrent miscarriage. Further studies on larger populations or across various ethnic groups, conclusions and the inclusion of other factors like epigenetic changes explain the role of AZF microdeletions in RPL.

Hysteroscopic features suggestive of chronic endometritis: a systematic review

The purpose of this systematic review is to identify common hysteroscopic findings suggestive of endometritis, chronic or subclinical, based on current scientific evidence. Data sources were MEDLINE, Embase, PubMed and other sources of grey literature. Four (4) authors independently selected studies addressing hysteroscopic detection of CE based on specific and clearly stated hysteroscopic criteria. The diagnosis was confirmed by histologic assessment, as stated in the materials and methods of these studies included. The initial search identified 599 studies, of which 21 met the inclusion criteria. Significant heterogeneity among published studies on Chronic endometritis (CE) remains the main limitation in performing a metanalysis and further analysis of diagnostic accuracy on the subject. Hysteroscopy is an important diagnostic tool in cases of chronic endometritis when accompanied by endometrial biopsies. Clinicians relate hyperaemia and endometrial oedema with chronic endometritis while more than half include micropolyposis as a pathognomonic feature of this subclinical condition. Micropolyps, stromal oedema, haemorrhagic spots, strawberry aspect, and hyperaemia are proposed as adequate indicators of hysteroscopic evidence of CE according to the literature. The impact of CE in long-term reproductive outcomes remain unclear, thus clinicians ought to communicate this to the patients and provide treatment where clinically appropriate. In addition, we present hysteroscopic images of histologically confirmed CE cases that could play the role of a hysteroscopic atlas.

High prevalence of chronic endometritis is associated with metabolic abnormality and reduced live birth rate among IVF women with non-uniform endometrial echogenicity

OBJECTIVE

To assess the prevalence of chronic endometritis (CE) among women with non-uniform endometrial echogenicity, and to evaluate the association between CE and metabolic characteristics as well as pregnancy outcomes in the subsequent frozen-thawed embryo transfer (FET) cycles.

DESIGN

Retrospective cohort study.

SETTING

University-based hospitals and an academic medical center.

PATIENTS

A total of 315 patients included in this research underwent hysteroscopy and endometrial biopsy before the first FET cycle after whole embryos freezing. Patients were divided into CE (histopathologic CE or hysteroscopic CE) and non-CE groups.

INTERVENTION(S)

Freeze-all strategy, hysteroscopy and endometrial biopsy.

MAIN OUTCOME MEASURES

Baseline and cycle characteristics, hysteroscopic, and histopathological profile, as well as pregnancy outcomes.

RESULTS

The prevalence of histopathologic CE and hysteroscopic CE were 78.1% and 34.9%, respectively. CE was associated with higher homocysteine level and BMI, independent of insulin response and dyslipidemia. High homocysteine level and BMI were risk factors for histopathologic CE (OR: 1.182; 95% CI: 1.01-1.384; p = .037) and hysteroscopic CE (OR: 1.117; 95% CI: 1.041-1.199; p = .002), respectively. Histopathologic CE was a risk factor for live birth (OR:2.167; 95% CI: 1.037-4.525; p = .04), and hysteroscopic CE was an independent risk factor for both live birth (OR: 4.239; 95% CI: 1.929-9.313; p = .001) and cumulative live birth (OR: 3.963; 95% CI: 1.875-8.376; p = .001).

CONCLUSIONS

Infertile women with non-uniform endometrial echogenicity have a high prevalence of CE which significantly reduces the live birth rate. Diagnosing CE by hysteroscopy is important to assess the cumulative probability of pregnancy in IVF patients.

The effect of chronic endometritis and treatment on patients with unexplained infertility

PURPOSE

This paper was mainly conducted to investigate the effect of chronic endometritis (CE) on the clinical outcome of patients with unexplained infertility.

MATERIALS AND METHODS

145 patients with unexplained infertility from the Reproductive Center of our hospital from January 2018 to December 2021 were selected as the unexplained infertility group. 42 patients with definite infertility causes were selected as the control group during the same period. Both groups of patients underwent hysteroscopy and immunohistochemical tests for CD38 and CD138. According to the results of hysteroscopy and immunohistochemistry, the incidence of CE between the two groups was analyzed. Patients with CE as CE group accepted oral antibiotic therapy for 14 days. Another 58 patients with unexplained infertility who did not undergo hysteroscopy and immunohistochemical tests for CD38 and CD138 were selected as the unexamined group. Both groups of patients were expected natural pregnancy. Follow-up lasted for 1 year, and the pregnant patients were followed up until delivery.The clinical pregnancy rate, spontaneous abortion rate and baby-carrying home rate of the two groups were compared.

RESULTS

There were 75 patients with CE in the unexplained infertility group, and the prevalence rate was 51.7% (75/145). Compared with the control group (28.6%), the incidence of CE was significantly higher (P < 0.05). After treated with antibiotic treatment, the patients' clinical pregnancy rate was 61.3% (46/75) and baby-carrying home rate was 60% (45/75) in the CE group, which were higher than those in the unexamined group(43.1% & 36.2%) (P < 0.05), while the spontaneous abortion rate was 2.2% (1/46),which was lower than that in the unexamined group (16.0%) (P < 0.05).

CONCLUSIONS

For patients with unexplained infertility, hysteroscopy combined with endometrial immunohistochemical detection of CD38 and CD138 should be performed in time to exclude CE. The clinical pregnancy outcome of CE patients can be significantly improved by antibiotic treatment.

Combined oral antibiotics and intrauterine perfusion can improve in vitro fertilization and embryo transfer pregnancy outcomes in patients with chronic endometritis and repeated embryo implantation failure

BACKGROUND

The aim of this retrospective study was to investigate whether oral antibiotics (doxycycline and metronidazole) combined with intrauterine perfusion (gentamicin and dexamethasone) are beneficial for patients with repeated implantation failure (RIF) and chronic endometritis (CE) to improve clinical pregnancy outcomes.

METHODS

Patients with RIF and CE were diagnosed using hysteroscopy and histology together. A total of 42 patients were enrolled in the study. All patients received oral antibiotics (doxycycline combined with metronidazole) and 22 patients underwent intrauterine perfusion (gentamicin combined with dexamethasone) immediately after the end of oral antibiotic therapy. Pregnancy outcomes were evaluated during the first in vitro fertilization (IVF) and embryo transfer (ET) cycle.

RESULTS

For the first D3 ET after treatment with oral antibiotics (doxycycline and metronidazole) combined with intrauterine perfusion (gentamicin and dexamethasone), higher embryo implantation rate (30.95% vs. 26.67%, P = 0.0308), clinical pregnancy rate (30% vs. 50%, P < 0.001), live birth rate (33.33% vs. 45.45%, P < 0.0001). No fetal malformations or ectopic pregnancies were observed.

CONCLUSION

We report oral antibiotics (doxycycline and metronidazole) combined with intrauterine perfusion (gentamicin and dexamethasone) as a novel treatment for CE to improve the outcomes of successful pregnancy compared with those of oral antibiotics alone.

ESHRE good practice recommendations on recurrent implantation failure

STUDY QUESTION

How should recurrent implantation failure (RIF) in patients undergoing ART be defined and managed?

SUMMARY ANSWER

This is the first ESHRE good practice recommendations paper providing a definition for RIF together with recommendations on how to investigate causes and contributing factors, and how to improve the chances of a pregnancy.

WHAT IS KNOWN ALREADY

RIF is a challenge in the ART clinic, with a multitude of investigations and interventions offered and applied in clinical practice, often without biological rationale or with unequivocal evidence of benefit.

STUDY DESIGN SIZE DURATION

This document was developed according to a predefined methodology for ESHRE good practice recommendations. Recommendations are supported by data from the literature, if available, and the results of a previously published survey on clinical practice in RIF and the expertise of the working group. A literature search was performed in PubMed and Cochrane focussing on 'recurrent reproductive failure', 'recurrent implantation failure', and 'repeated implantation failure'.

PARTICIPANTS/MATERIALS SETTING METHODS

The ESHRE Working Group on Recurrent Implantation Failure included eight members representing the ESHRE Special Interest Groups for Implantation and Early Pregnancy, Reproductive Endocrinology, and Embryology, with an independent chair and an expert in statistics. The recommendations for clinical practice were formulated based on the expert opinion of the working group, while taking into consideration the published data and results of the survey on uptake in clinical practice. The draft document was then open to ESHRE members for online peer review and was revised in light of the comments received.

MAIN RESULTS AND THE ROLE OF CHANCE

The working group recommends considering RIF as a secondary phenomenon of ART, as it can only be observed in patients undergoing IVF, and that the following description of RIF be adopted: 'RIF describes the scenario in which the transfer of embryos considered to be viable has failed to result in a positive pregnancy test sufficiently often in a specific patient to warrant consideration of further investigations and/or interventions'. It was agreed that the recommended threshold for the cumulative predicted chance of implantation to identify RIF for the purposes of initiating further investigation is 60%. When a couple have not had a successful implantation by a certain number of embryo transfers and the cumulative predicted chance of implantation associated with that number is greater than 60%, then they should be counselled on further investigation and/or treatment options. This term defines clinical RIF for which further actions should be considered. Nineteen recommendations were formulated on investigations when RIF is suspected, and 13 on interventions. Recommendations were colour-coded based on whether the investigations/interventions were recommended (green), to be considered (orange), or not recommended, i.e. not to be offered routinely (red).

LIMITATIONS REASONS FOR CAUTION

While awaiting the results of further studies and trials, the ESHRE Working Group on Recurrent Implantation Failure recommends identifying RIF based on the chance of successful implantation for the individual patient or couple and to restrict investigations and treatments to those supported by a clear rationale and data indicating their likely benefit.

WIDER IMPLICATIONS OF THE FINDINGS

This article provides not only good practice advice but also highlights the investigations and interventions that need further research. This research, when well-conducted, will be key to making progress in the clinical management of RIF.

STUDY FUNDING/COMPETING INTERESTS

The meetings and technical support for this project were funded by ESHRE. N.M. declared consulting fees from ArtPRED (The Netherlands) and Freya Biosciences (Denmark); Honoraria for lectures from Gedeon Richter, Merck, Abbott, and IBSA; being co-founder of Verso Biosense. He is Co-Chief Editor of Reproductive Biomedicine Online (RBMO). D.C. declared being an Associate Editor of Human Reproduction Update, and declared honoraria for lectures from Merck, Organon, IBSA, and Fairtility; support for attending meetings from Cooper Surgical, Fujifilm Irvine Scientific. G.G. declared that he or his institution received financial or non-financial support for research, lectures, workshops, advisory roles, or travelling from Ferring, Merck, Gedeon-Richter, PregLem, Abbott, Vifor, Organon, MSD, Coopersurgical, ObsEVA, and ReprodWissen. He is an Editor of the journals Archives of Obstetrics and Gynecology and Reproductive Biomedicine Online, and Editor in Chief of Journal Gynäkologische Endokrinologie. He is involved in guideline developments and quality control on national and international level. G.L. declared he or his institution received honoraria for lectures from Merck, Ferring, Vianex/Organon, and MSD. He is an Associate Editor of Human Reproduction Update, immediate past Coordinator of Special Interest Group for Reproductive Endocrinology of ESHRE and has been involved in Guideline Development Groups of ESHRE and national fertility authorities. D.J.M. declared being an Associate Editor for Human Reproduction Open and statistical Advisor for Reproductive Biomedicine Online. B.T. declared being shareholder of Reprognostics and she or her institution received financial or non-financial support for research, clinical trials, lectures, workshops, advisory roles or travelling from support for attending meetings from Ferring, MSD, Exeltis, Merck Serono, Bayer, Teva, Theramex and Novartis, Astropharm, Ferring. The other authors had nothing to disclose.

DISCLAIMER

This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation. ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type. Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

Endometrial Biopsy: Indications, Techniques and Recommendations. An Evidence-Based Guideline for Clinical Practice

This practice guideline provides updated evidence for the gynecologist who performs endometrial biopsy (EB) in gynecologic clinical practice. An international committee of gynecology experts developed the recommendations according to AGREE Reporting Guideline. An adequate tissue sampling is mandatory when performing an EB. Blind methods should not be first choice in patients with suspected endometrial malignancy. Hysteroscopy is the targeted-biopsy method with highest diagnostic accuracy and cost-effectiveness. Blind suction techniques are not reliable for the diagnosis of endometrial polyps. In low resources settings, and in absence of the capacity to perform office hysteroscopy, blind techniques could be used for EB. Hysteroscopic punch biopsy allows to collect only limited amount of endometrial tissue. grasp biopsy technique should be considered first choice in reproductive aged women, bipolar electrode chip biopsy should be preferred with hypotrophic or atrophic endometrium. EB is required for the final diagnosis of chronic endometritis. There is no consensus regarding which endometrial thickness cut-off should be used for recommending EB in asymptomatic postmenopausal women. EB should be offered to young women with abnormal uterine bleeding and risk factors for endometrial carcinoma. Endometrial pathology should be excluded with EB in nonobese women with unopposed hyperestrogenism. Hysteroscopy with EB is useful in patients with abnormal bleeding even without sonographic evidence of pathology. EB has high sensitivity for detecting intrauterine pathologies. In postmenopausal women with uterine bleeding, EB is recommended. Women with sonographic endometrial thickness > 4mm using tamoxifen should undergo hysteroscopic EB.

Dynamics of inflammatory cytokine expression in bovine endometrial cells exposed to cow blood plasma small extracellular vesicles (sEV) may reflect high fertility

Aberrant inflammation in the endometrium impairs reproduction and leads to poor fertility. Small extracellular vesicles (sEV) are nanoparticles 30-200 nm in-size and contain transferable bioactive molecules that reflect the parent cell. Holstein-Friesian dairy cows with divergent genetic merit, high- (n = 10) and low-fertile (n = 10), were identified based on fertility breeding value (FBV), cow ovulation synchronization and postpartum anovulatory intervals (PPAI). In this study, we evaluated the effects of sEVs enriched from plasma of high-fertile (HF-EXO) and low-fertile (LF-EXO) dairy cows on inflammatory mediator expression by bovine endometrial epithelial (bEEL) and stromal (bCSC) cells. Exposure to HF-EXO in bCSC and bEEL cells yielded lower expression of PTGS1 and PTGS2 compared to the control. In bCSC cells exposed to HF-EXO, pro-inflammatory cytokine IL1-α was downregulated compared to the untreated control, IL-12α and IL-8 were downregulated compared to the LF-EXO treatment. Our findings demonstrate that sEVs interact with both endometrial epithelial and stromal cells to initiate differential gene expression, specifically genes relate to inflammation. Therefore, even subtle changes on the inflammatory gene cascade in the endometrium via sEV may affect reproductive performance and/or outcomes. Further, sEV from high-fertile animals acts in a unique direction to deactivate prostaglandin synthases in both bCSC and bEEL cells and deactivate pro-inflammatory cytokines in the endometrial stroma. The results suggest that circulating sEV may serve as a potential biomarker of fertility.

Chronic endometritis positively correlates with the aggravation of intrauterine adhesions but has limited effects on reproductive prognosis with antibiotic application

OBJECTIVE

To assess the effect of chronic endometritis (CE) diagnosed by CD138 staining on the aggravation of intrauterine adhesions (IUAs), and the reproductive prognosis after transcervical resection of adhesions (TCRA).

METHODS

Sixty-three patients with severe IUAs (group A) and 119 patients with moderate IUAs (group B) were included in this retrospective study. TCRA and endometrial biopsy with CD138 staining were performed. Participants in each group were classified into two subgroups: CE group and NCE group (without CE). Patients were treated with a course of oral antibiotics for 2 weeks after TCRA. Embryo transfer would be performed if patients had embryos after operations.

RESULTS

Increased incidence of CE was found in group A (18/63, 28.57%) compared with group B (18/119, 15.13%) (P = 0.030). No significant differences were found in the comparisons of chemical pregnancy rate, early miscarriage rate, or full-term pregnancy rate between the CE group and NCE group (P > 0.05), in either the subgroup analysis of group A and group B, or the total analysis.

CONCLUSION

CE has a positive correlation with the aggravation of IUAs. CE did not have a negative impact on the reproductive prognosis of patients with moderate or severe IUAs after TCRA followed by antibiotic administration.

Analysis of pregnancy outcomes in patients with recurrent implantation failure complicated with chronic endometritis

Chronic endometritis (CE) has been considered to reduce uterine receptivity and negatively affect reproductive outcomes for in vitro fertilization-embryo transfer (IVF-ET) patients, especially for people undergoing recurrent implantation failure (RIF). To investigate the effects of antibiotic and platelet-rich plasma (PRP) therapy on pregnancy outcomes following frozen-thawed embryo transfer (FET) in RIF patients with CE, endometrial specimens of 327 patients with RIF obtained by endometrial scratching during mid-luteal phase were immunostained by multiple myeloma oncogene-1 (Mum-1)/syndecan-1 (CD138). RIF patients with CE were given antibiotics and PRP treatment. According to the Mum-1⁺/CD138⁺ plasmacytes after treatment, patients were divided into persistent weak positive CE (+) group, CE (-) group and non-CE group. FET was performed and the basic characteristics and pregnancy outcomes of patients in three groups were compared. Among 327 RIF patients, 117 patients were complicated with CE, the prevalence was 35.78%. The prevalence of strong positive was 27.22% and that of weak positive was 8.56%. 70.94% patients with CE converted to negative after treatment. There was no significant difference in the basic characteristics, including age, BMI, AMH, AFC, infertility years, infertility types, number of previous transplant cycles, endometrial thickness on transplantation day and number of transplanted embryos (p > 0.05); The positive rate of hCG, clinical pregnancy rate and implantation rate in CE (-) group were significantly increased compared with the weak CE (+) group and non-CE group (p < .01), and the live birth rate also improved (p < .05). Whereas, the rate of early abortion in CE (-) group was 12.70%, which was higher than that in weak CE (+) group and non-CE group (p < .05). After multivariate analysis, number of previous failed cycles and CE remained independent factors associated with live birth rate, while only CE remained to be the independent factor of clinical pregnancy rate. It is recommended to perform CE-related examination for patients with RIF. Antibiotic and PRP treatment can significantly improve pregnancy outcomes of patients with CE negative conversion in FET cycle.

The effectiveness of intrauterine antibiotic infusion versus oral antibiotic therapy in the treatment of chronic endometritis in patients during IVF (in vitro fertilization) procedures

BACKGROUND

Chronic Endometritis (CE) is a subtle pathology, likely infectious in most cases, with a negative impact on the female fertility, but often overlooked even among fertility specialists. The purpose of the study is to demonstrate the predominant infectious nature of CE and to find the best therapeutic option by comparing the results of oral antibiotic therapy versus intrauterine antibiotic infusion in patients with CE undergoing IVF procedures. The objective was to compare the cure rate of CE-defined as the percentage of patients without CE at the test of cure, between the two groups and, the hysteroscopic aspect with the positive CD 138 staining.

METHODS

This was a prospective, case-control study that took place in a single university fertility clinic, in Oradea, Romania and included 57 patients with CE divided into 2 groups: orally administered antibiotics group who received a combination of antibiotics compared to intrauterine infusion group who received intrauterine infusion of antibiotic. Chronic Endometritis was diagnosed through hysteroscopy and immunohistochemistry for CD 138. Patients in both groups were tested for CE twice to evaluate the cure rate after oral combination antibiotic therapy versus intrauterine infusion of antibiotic.

RESULTS

Out of 115 patients with endometrial biopsies 57 tested positive for CE, with a 49.6% chronic endometritis prevalence. Among the group that was administered oral antibiotics, 11 patients (45.83%) experienced CE resolution after triple antibiotic therapy. Of the intrauterine infusion group, 25 patients (89.29%) presented negative results (p 0.0020). The normal hysteroscopic aspect had a similar prevalence in the patients with immunohistochemical positive and negative CD 138.

CONCLUSIONS

Our study demonstrated the effectiveness and superiority of intrauterine antibiotic infusion over the use of oral combination antibiotic therapy for CE cure.

TRIAL REGISTRATION

ISRCTN17542620/14.09.2022.

The menstrual cycle phase impacts the detection of plasma cells and the diagnosis of chronic endometritis in endometrial biopsy specimens

OBJECTIVE

To assess the impact of menstrual cycle phase on the detection of plasma cells.

DESIGN

A retrospective cohort study.

SETTING

Fertility clinic.

PATIENT(S)

Biopsies from 157 patients met criteria for inclusion, 91 in the follicular phase and 60 in the luteal phase. Patient groups were similar in body mass index and number of previous live births; however, differed in terms of age, infertility history, and biopsy indication.

INTERVENTIONS

Endometrial biopsies from patients at a fertility clinic from 2018-2020 were retrospectively reviewed. Biopsies were excluded if patients had a previous chronic endometritis diagnosis, abnormal uterine cavity or were on hormone therapy. Each case was reviewed by a gynecologic pathologist for plasma cells by hematoxylin and eosin and CD138 staining. Demographic and clinical data were collected. Continuous variables were compared using Welch t test and Wilcoxon's rank sum test, and categorical variables using Pearson's χ² test. Logistic regression was used to calculate odds ratio and 95% confidence intervals for the association between the presence of plasma cells and cycle phase. Multinomial logistic regression was used to estimate the odds ratios for nominal outcomes. Pathology reports were reviewed. Plasma cell enumeration using hematoxylin and eosin-stained sections and CD138 immunohistochemical stains (performed at the time of biopsy by a gynecologic pathologist) was recorded.

MAIN OUTCOME MEASURE(S)

Presence and density of plasma cells.

RESULT(S)

We found a higher likelihood of finding plasma cells in the follicular than in luteal phase (59.3% vs. 19.7%). There was a higher likelihood of finding plasma cells in the early (cycle days 5-8, 29 cases or 76.3% of cases with plasma cells) than in the late follicular phase (cycle days 9-14, 25 cases or 47.2%). There was a higher density of plasma cells in the follicular phase group than in the luteal phase group (25.3% vs. 1.5% scattered and 13.2% vs. 0 clusters).

CONCLUSION(S)

Plasma cells are more likely to be present during the follicular phase compared with the luteal phase and in the early compared with the late follicular phase. Further studies are needed to identify the optimal timing of biopsy to standardize the diagnosis.

Chronic Endometritis in Infertile Women: Impact of Untreated Disease, Plasma Cell Count and Antibiotic Therapy on IVF Outcome-A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aims to evaluate the impact of chronic endometritis (CE) and its therapy on in vitro fertilization (IVF) outcome. Additionally, we aim to investigate whether various degrees of CE severity may exert a different effect on IVF outcome. Ongoing-pregnancy rate/live-birth-rate (OPR/LBR), clinical-pregnancy rate (CPR), and miscarriage rate (MR) were calculated. A total number of 4145 patients (from ten studies) were included. Women with CE had lower OPR/LBR (OR 1.97, p = 0.02) and CPR (OR 2.28, p = 0.002) compared to those without CE. CE cure increased OPR/LBR (OR 5.33, p < 0.0001) and CPR (OR 3.64, p = 0.0001). IVF outcome was comparable between women with cured CE and those without CE (OPR/LBR, CPR and MR: p = ns). Women with severe CE had lower OPR/LBR (OR 0.43, p = 0.003) and CPR (OR 0.40, p = 0.0007) compared to those mild CE. Mild CE showed no influence on the IVF outcome as compared to women without CE (OPR/LBR, CPR and MR: p = ns). Based on this data analysis, CE significantly reduces OPR/LBR and CPR in women undergoing IVF. Importantly, CE resolution after antibiotic therapy may improves IVF outcome, leading to similar OPR/LBR and CPR as compared to unaffected patients. The negative effects of CE on IVF outcome may be restricted to severe disease, whereas mild CE may have no influence on IVF success.

Does antibiotic therapy for chronic endometritis improve clinical outcomes of patients with recurrent implantation failure in subsequent IVF cycles? A systematic review and meta-analysis

PURPOSE

This study aims to assess whether antibiotic therapy for chronic endometritis (CE) could improve subsequent IVF outcomes in patients with recurrent implantation failure (RIF).

METHODS

Studies that explore CE treatment in patients with RIF were retrieved from PubMed, EMBASE, Wanfang, and Google Scholar up to Jan 31, 2022. All retrieved studies were selected according to the inclusion and exclusion criteria. The main outcome measures include implantation rate (IR), clinical pregnancy rate (CPR), ongoing pregnancy rate/live birth rate (OPR/LBR), and miscarriage rate (MR). Odds ratios (ORs) were analyzed for pregnancy outcomes with a 95% confidence interval (CI).

RESULTS

Nine articles were enrolled in this study. Patients receiving oral antibiotic administration (OAA) did not show any advantage over patients without CE with regard to IR, OPR/LBR, and MR, but they showed a higher CPR. Patients with cured CE after OAA therapy had significantly higher CPR, IR, and OPR/LBR compared with patients without CE. Patients with persistent CE after OAA therapy had significantly lower IR, CPR, and OPR/LBR compared with patients without CE. Patients with cured CE had significantly higher IR, CPR, and OPR/LBR compared with persistent CE patients.

CONCLUSIONS

Antibiotic treatment may improve the pregnancy outcomes of RIF patients in subsequent IVF cycles only if the condition of CE is confirmed cured in a control biopsy afterwards. Otherwise, no sufficient evidence has shown improvements in clinical outcomes in RIF patients with persistent CE.

Recurrent implantation failure and sexual function in infertile Iranian women: a comparative cross sectional study

Background

Recurrent implantation failure (RIF) which means failing to implant after two or more high-quality embryo transfer cycles, affects 3% to 5% of women worldwide. The aim of this study was to assess the relationship between recurrent implantation failure and sexual function in infertile Iranian women.

Methods

This was a comparative cross-sectional study on 180 infertile Iranian women (90 infertile women with recurrent implantation failure and 90 infertile women who did not start infertility treatment). A demographic questionnaire and the Female Sexual Function Index were used for data collection. Data were analyzed using Chi-square, independent t-test, and multiple linear regression.

Results

The mean scores of different domains of sexual function (desire, lubrication, arousal, orgasm, pain, and satisfaction) were significantly lower in the group with RIF compared to the group without RIF. The total score of sexual function was significantly lower in the RIF group compared with the group without RIF (23.11 ± 2.24, vs. 25.99 ± 2.35, p < 0.001). The overall sexual function scores in women with RIF were 2.65 units lower than women without RIF (p < 0.001).

Conclusion

The results of this study showed that women with RIF had significantly lower sexual function than that in women without RIF. Therefore, sexual function issues should be treated as an important component of comprehensive care. This study did not measure the impact of economic factors on sexual function, however, the majority of the sample were classified as having weak or moderate economic status and this, along with the high cost of infertility treatments, could potentially have played a role in the participants' experience. This relationship will need to be investigated in future research.

Recurrent implantation failure (RIF) means inability to implant after two or more high-quality embryo transfer cycles. The aim of this study was to assess the relationship between recurrent implantation failure and sexual function in infertile Iranian women. In this study, 180 infertile Iranian women (including 90 infertile women with recurrent implantation failure and 90 infertile women with no implantation failure) were recruited. A demographic questionnaire and the Female Sexual Function Index were used for data collection. The mean scores of different domains of sexual function (desire, lubrication, arousal, orgasm, pain, and satisfaction) were significantly lower in the group with recurrent implantation failure compared to the group without. The overall sexual function scores in the RIF group were 2.65 units lower than those of women without RIF. Women experiencing recurrent implantation failure may be at a particular risk of reduced sexual function. Therefore, sexual function issues should be treated as an important component of comprehensive care.

The role of endometrial B cells in normal endometrium and benign female reproductive pathologies: a systematic review

STUDY QUESTION

What are the similarities and differences in endometrial B cells in the normal human endometrium and benign reproductive pathologies?

SUMMARY ANSWER

Endometrial B cells typically constitute <5% of total endometrial CD45+ lymphocytes, and no more than 2% of total cells in the normal endometrium, and while their relative abundance and phenotypes vary in benign gynaecological conditions, current evidence is inconsistent.

WHAT IS KNOWN ALREADY

B cells are vitally important in the mucosal immune environment and have been extensively characterized in secondary lymphoid organs and tertiary lymphoid structures (TLSs), with the associated microenvironment germinal centre. However, in the endometrium, B cells are largely overlooked, despite the crucial link between autoimmunity and reproductive pathologies and the fact that B cells are present in normal endometrium and benign female reproductive pathologies, scattered or in the form of lymphoid aggregates (LAs). A comprehensive summary of current data investigating B cells will facilitate our understanding of endometrial B cells in the endometrial mucosal immune environment.

STUDY DESIGN SIZE DURATION

This systematic review retrieved relevant studies from four databases (MEDLINE, EMBASE, Web of Science Core Collection and CINAHL) from database inception until November 2021.

PARTICIPANTS/MATERIALS SETTING METHODS

The search strategy combined the use of subject headings and relevant text words related to 'endometrium', 'B cells' and B-cell derivatives, such as 'antibody' and 'immunoglobulin'. Non-benign diseases were excluded using cancer-related free-text terms, and searches were limited to the English language and human subjects. Only peer-reviewed research papers were included. Each paper was graded as 'Good', 'Fair' or 'Poor' quality based on the NEWCASTLE-OTTAWA quality assessment scale. Only 'Good' quality papers were included.

MAIN RESULTS AND THE ROLE OF CHANCE

Twenty-seven studies met the selection criteria and were included in this review: 10 cross-sectional studies investigated B cells in the normal endometrium; and 17 case-control studies compared the characteristics of endometrial B cells in control and benign female reproductive pathologies including endometritis, endometriosis, infertility, abnormal uterine bleeding, endometrial polyps and uterine fibroids. In all studies, B cells were present in the endometrium, scattered or in the form of LAs. CD20+ B cells were more abundant in patients with endometritis, but the data were inconsistent as to whether B-cell numbers were increased in endometriosis and patients with reproductive pathologies.

LIMITATIONS REASONS FOR CAUTION

Although only 'good' quality papers were included in this systematic review, there were variations in patients' age, diagnostic criteria for different diseases and sample collection time among included studies. Additionally, a large number of the included studies only used immunohistochemistry as the identification method for endometrial B cells, which may fail to provide an accurate representation of the numbers of endometrial B cells.

WIDER IMPLICATIONS OF THE FINDINGS

Histological studies found that endometrial B cells are either scattered or surrounded by T cells in LAs: the latter structure seems to be under hormonal control throughout the menstrual cycle and resembles TLSs that have been observed in other tissues. Further characterization of endometrial B cells and LAs could offer insights to endometrial B-cell function, particularly in the context of autoimmune-associated pathologies, such as endometriosis. Additionally, clinicians should be aware of the limited value of diagnosing plasma cell infiltration using only CD138.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Finox Biotech. The authors have no conflicts of interest to declare.

PROSPERO REGISTRATION NUMBER

This systematic review was registered in PROSPERO in January 2020 (PROSPERO ID: CRD42020152915).

Hysteroscopic findings in chronic endometritis

Chronic endometritis (CE) is a subtle pathology. Despite being difficult to detect and probably underdiagnosed, it has great clinical relevance, representing as it does a reversible cause of infertility. Nowadays, histological examination with identification of endometrial stromal plasma cells is considered the gold standard for diagnosis. Diagnostic difficulties persist, however, as a result of the technical limitations of this method and the lack of standardized histological diagnostic criteria. Hysteroscopy has been proposed as an aid for CE diagnosis. The method works by detecting signs of inflammation (focal or diffuse hyperemia, stromal edema, presence of micropolyps and the typical strawberry aspect) on the endometrial surface. Yet, the jury is still out on how reliable this technique is. Hysteroscopy displays a high sensitivity (over 86% and up to 100%) and high negative predictive value (over 92% and up to 100%) in the diagnosis of CE, and it should probably be performed routinely in the assessment of patients with unexplained infertility, repeated implantation failure and repeated pregnancy loss; however, since values in the literature regarding specificity are conflicting, in cases of suspected CE, hysteroscopy may be combined with histological examination, which remains the gold standard to confirm CE. Considering that histopathological evaluation probably underdiagnoses CE, and that hysteroscopy tends to overdiagnose, further studies are needed to determine which technique (or combination of techniques) has greater value for patients.

Association between Endometrial Polyps and Chronic Endometritis: Is It Time for a Paradigm Shift in the Pathophysiology of Endometrial Polyps in Pre-Menopausal Women? Results of a Systematic Review and Meta-Analysis

BACKGROUND

Chronic endometritis (CE) and endometrial polyps (EPs) are common conditions in reproductive age women. CE is an infectious disorder of the endometrium characterized by signs of chronic inflammation at hysteroscopic and histological analyses. EPs are abnormal endometrial growths containing glands, stroma and blood vessels projecting from the lining of the uterus. During the last years, different authors have investigated the correlation between CE and EPs, with controversial results. The aim of this study was to summarize available evidence on the potential correlation between CE and EPs.

DESIGN

Systematic literature review and meta-analysis.

METHODS

Observational-studies were identified by searching electronic databases from their inception to September 2021. Only studies on pre-menopausal women were included. Statistical analysis was performed using MedCalc 16.4.3 (Ostend, Belgium) and Review Manager version 5.3 (Nordic Cochrane Centre, Cochrane Collaboration). The summary measures were reported as pooled proportion or odds ratio (OR) with 95% confidence interval (CI). The primary outcome was to evaluate the prevalence of CE in women with EPs. The secondary outcome was to determine the prevalence of CD-138-positive EPs among EPs. Tertiary outcomes were to compare the prevalence of CE in women with EPs versus women with a non-polypoid endometrium and to compare the prevalence of CE in women with a single EP versus women with multiple EPs.

RESULTS

Eight observational studies (n = 3225 patients) were included in quantitative synthesis. Pooled prevalence of CE among women with EPs was 51.35% (95% CI, 27.24-75.13%). Pooled proportion of CD-138-positive EPs among EPs was 70.73% (95% CI, 55.73-83.68%). Women with EPs showed higher prevalence of CE compared to women without EPs (OR 3.07, 95% CI 1.59-5.95). Women with ≥3 EPs had higher prevalence of CE then women with a single EP (OR 3.43, 95% CI 1.83-6.46).

CONCLUSIONS

In pre-menopausal women, CE and EPs may have a dependent relationship and may represent two consequent steps of a common pathological process.

Relation between chronic endometritis and recurrent miscarriage

Introduction

Growing interest has focused on the relation between chronic endometritis (CE) or asymptomatic inflammation of the endometrium and recurrent miscarriage (RM).The aim of the study was to assess the relation between CE and RM and the accuracy of hysteroscopy in diagnosing CE.

Material and methods

One hundred and ten (110) women with unexplained RM were included in this study. Participants were subjected to diagnostic hysteroscopy for uterine cavity, and endometrium evaluation. The diagnosis of CE during hysteroscopic examination was based on CE-related hysteroscopic signs (micro-polyps, stromal edema, and/or hyperemia). At the end of hysteroscopy, an endometrial biopsy was taken from participants for culture, and immunohistochemical (IHC) staining. Collected data were analyzed to assess the relation between CE and RM and the accuracy of hysteroscopy in diagnosing CE.

Results

The prevalence of CE in women with RM was 31.8% using CE-related hysteroscopic signs, while it was 38.2% using IHC staining and endometrial cultures (p = 0.4). CE-related hysteroscopic signs had 64.1% sensitivity, 85.9% specificity, 71.4% positive predictive value (PPV), 81.3% negative predictive value (NPV), and 78.2% overall accuracy in diagnosing CE. Most cases of CE (> 81%) were caused by Mycoplasma and common pathogens.

Conclusions

The prevalence of CE in women with RM was 31.8% using CE-related hysteroscopic signs, while it was 38.2% using IHC staining and endometrial cultures. CE-related hysteroscopic signs had 64.1% sensitivity, 85.9% specificity, 71.4% PPV, 81.3% NPV, and 78.2% overall accuracy in diagnosing CE. Most cases of CE (> 81%) were caused by Mycoplasma and common pathogens.

B Cell Subset Analysis and Gene Expression Characterization in Mid-Luteal Endometrium

The human endometrium is the innermost mucosal membrane of the uterus and is the first point of contact for an implanting blastocyst. A wide variety of immune cells are found amongst the endometrial epithelial layers and stromal cells which both provide host immune responses against pathogens and also assist with placentation and pregnancy establishment, however, B cells have not been characterized, despite being a vital player in both adaptive and mucosal immunity. Through analysis of mid-luteal endometrial biopsies, we find 1–5% of endometrial immune cells are B cells, the majority were naïve or memory B cells, with few plasma cells. Compared with circulating B cells, endometrial B cells had an activated phenotype, with increased expression of CD69, HLA-DR, CD74, and CD83, and IL-10 production capacities. PD1⁺CXCR5⁺ICOS⁺ T follicular helper-like cells and FAS⁺IgD^–BCL6⁺ germinal center B cells were also present in the endometrium, which may indicate that endometrial B cells are playing an active role through germinal center reactions in the human endometrial environment.

Correlation between hysteroscopy findings in patients with hydrosalpinx and chronic endometritis

OBJECTIVE

To evaluate the role of hydrosalpinx in susceptibility to chronic endometritis (CE).

METHODS

This is a retrospective cohort study, which includes 624 patients with hydrosalpinx (group A) and 789 patients without hydrosalpinx (group B) undergoing laparoscopy and hysteroscopy simultaneously. Endometrial morphology was recorded under hysteroscopy. Endometrial biopsy was obtained after hysteroscopy, and immunohistochemical staining for syndecan-1 (CD138) was carried out.

RESULTS

No significantly statistical differences were found between the two groups when comparing the incidence of endometrial hyperemia or endometrial micro-polyps under hysteroscopy (P > 0.05). Hydrosalpinx had a significant impact on the incidence of CE (P < 0.05) (plasma cell count: no plasma cells: odds ratio [OR] 0.71, 95% confidence interval [CI] 0.58-0.88, P = 0.002; ≥1/high-power field [HPF]: OR 1.40, 95% CI 1.14-1.74, P = 0.002; ≥3/HPF: OR 1.50, 95% CI 1.18-1.91, P = 0.001; ≥5/HPF: OR 1.62, 95% CI 1.27-2.21, P < 0.001). There were no significant differences in the comparison of plasma cell count between the unilateral hydrosalpinx group (274 patients) and the bilateral hydrosalpinx group (350 patients) (P > 0.05).

CONCLUSION

The presence of hydrosalpinx increased the incidence of CE. Bilateral hydrosalpinx did not significantly increase the incidence of CE compared with unilateral hydrosalpinx.

Treatment following hysteroscopy and endometrial diagnostic biopsy increases the chance for live birth in women with chronic endometritis

Problem

Repeated implantation failure and recurrent pregnancy loss are associated with chronic endometritis, a persistent endometrial inflammation. Its diagnosis and treatment may increase pregnancy and live birth rates. The aim of this study was to assess the effectiveness of endometrial diagnostic biopsy and subsequent antibiotic treatment in cases of chronic endometritis on reproductive outcomes over a long observation period.

Method of Study

We conducted a historical cohort study (2014–2018) at our University‐based infertility center that included women (n = 108) with repeated implantation failure or recurrent pregnancy loss without known pathologies associated with either condition. Forty‐one women underwent a hysteroscopy only (reference group); the remaining 67 women underwent, in addition to the hysteroscopy, an endometrial diagnostic biopsy with immunohistochemically staining for CD138 to detect plasma cells (biopsy group). If one or more plasma cells were detected, the women were treated with doxycycline 100 mg twice a day orally for 2 weeks. We performed stratified survival analysis (Kaplan‐Meier) and Cox regression.

Results

The biopsy group had higher chances of pregnancy (hazard ratio 2.28; 95% confidence interval 1.23–4.24; p = .009) and of live birth (hazard ratio 2.76; 95% confidence interval 1.30–5.87; p = .008) compared with the reference group. In the sensitivity analysis, repeated implantation failure or recurrent pregnancy loss did not affect the outcome.

Conclusion

Endometrial diagnostic biopsy followed by antibiotic treatment in case of chronic endometritis in women with repeated implantation failure or recurrent pregnancy loss may increase the chances for live birth.

Redefining chronic endometritis: the importance of endometrial stromal changes

OBJECTIVE

To develop diagnostic criteria for chronic endometritis and compare the prevalence of chronic endometritis between women with recurrent pregnancy loss (RPL) and controls.

DESIGN

Cohort study.

SETTING

Single academic fertility center.

PATIENTS

Women with unexplained RPL (two or more pregnancy losses) and prospectively recruited controls without a history of RPL or infertility.

INTERVENTIONS

Endometrial samples were stained with hematoxylin and eosin and CD138. A pathologist blinded to patient history recorded the number of plasma cells per 10 high-power fields (HPFs). In addition, the presence or absence of endometrial stromal changes was documented.

MAIN OUTCOME MEASURE

Prevalence of chronic endometritis.

RESULTS

Endometrial samples from 50 women with unexplained RPL and 26 controls were evaluated. When chronic endometritis was defined as the presence of one or more plasma cells per 10 HPFs, 31% of controls and 56% of women with RPL met the criterion. When both endometrial stromal changes and plasma cells were required for a diagnosis of chronic endometritis, no controls and 30% of women with RPL met the criteria.

CONCLUSIONS

Although rare plasma cells were found in biopsy samples from controls, the presence of both plasma cells and endometrial stromal changes was limited to the RPL cohort. We propose that chronic endometritis be defined as the presence of one or more plasma cells per 10 HPFs in the setting of endometrial stromal changes. With the use of these strict diagnostic criteria, women with RPL have a significantly higher rate of chronic endometritis, supporting an association between chronic endometritis and RPL.

Characterization of the vaginal and endometrial microbiome in patients with chronic endometritis

OBJECTIVE

To compare the endometrial and vaginal microbiome of women with and without chronic endometritis.

STUDY DESIGN

A cohort study with 60 patients undergoing assisted reproductive treatment with their own or donated gametes was undertaken. Vaginal and endometrial samples were taken in the cycle prior to embryo transfer. The endometrial and vaginal microbiome was analysed by mass sequencing of the V3V4 region of 16S rRNA gene. Bioinformatics analysis was performed using QIIME2 and MicrobiomeAnalyst packages. Alpha diversity, beta diversity and taxonomic characterization were compared between samples that tested positive and negative for chronic endometritis on CD138 immunohistochemistry.

RESULTS

Different bacterial communities were detected when vaginal and endometrial samples were analysed in patients with and without endometritis diagnosed using CD138 immunohistochemistry. In patients with endometritis, a higher alpha-diversity index was found in vaginal samples (p = 0.15 for the Shannon index) and significant differences were found in endometrial samples (p = 0.01 for the Shannon index). In the beta-diversity analysis, no significant differences were observed between the groups with and without endometritis. Vaginal and endometrial samples from women with endometritis showed a microbiome pattern that was not dominated by Lactobacillus spp. Relative abundance analysis identified Ralstonia and Gardnerella spp. in endometrial samples, and Streptoccoccus and Ureaplasma spp. in vaginal samples of patients diagnosed with chronic endometritis on CD138 immunohistochemistry. When comparing endometrial and vaginal samples diagnosed with endometritis on CD138 immunohistochemistry, both alpha diversity (p = 0.06 for the Shannon index and p = 0.08 for the Simpson index) and beta diversity (p < 0.001) showed significant differences. Lactobacillus spp. (p = 3.76E-4), Ralstonia spp. (p = 8.19E-4), Delftia spp. (p = 0.004) and Anaerobacillus spp. (p = 0.004) were identified in these sample groups.

CONCLUSION

These results demonstrate the existence of a characteristic vaginal and endometrial microbiota in patients with chronic endometritis. Different genera and species were identified in patients with and without chronic endometritis depending on whether the sample was endometrial or vaginal. There is a clear relationship between changes in the vaginal microbiome and chronic endometritis. The microbiota is a continuum throughout the female reproductive tract, so study of the vaginal microbiota could be useful for the diagnosis of diseases of the upper reproductive tract, such as chronic endometritis.

Is Chronic Endometritis Associated with Tubal Infertility? A Prospective Cohort Study

STUDY OBJECTIVE

Chronic endometritis (CE), which often presents asymptomatically, is associated with recurrent pregnancy loss, recurrent implantation failure after in vitro fertilization, and endometriosis. Data connecting CE with fallopian tubal occlusion are limited. The aim was to assess a potential association of CE, defined by the presence of syndecan-1 (CD138)-positive plasma cells in endometrial tissue samples, with fallopian tube patency and other factors for infertility, including endometriosis, adenomyosis, and hydrosalpinges.

DESIGN

Prospective, monocentral pilot study.

SETTING

Tertiary care center.

PATIENTS

A cohort of 100 women who were infertile was enrolled from July 2019 to December 2020.

INTERVENTIONS

Hysteroscopy with endometrial biopsy and laparoscopy with chromopertubation.

MEASUREMENTS AND MAIN RESULTS

CE was found in 13 women (13.0%) and was associated with endometriosis (p = .034) and unilateral/bilateral fallopian tube blockage (p = .013). In women with endometriosis, the mean number of CD138-positive cells was positively correlated with the revised American Society for Reproductive Medicine score (r = .302, p = .028). In a binary regression model, the presence of a hydrosalpinx on one or both sides (odds ratio 15.308; 95% confidence interval, 1.637-143.189; p = .017) and the finding of CE in the endometrial tissue sample (odds ratio 5.273; 95% confidence interval, 1.257-22.116; p = .023) were significantly associated with fallopian tubal occlusion.

CONCLUSION

CE was significantly associated with blockage of the fallopian tubes and endometriosis. Endometriosis stage was associated with the number of CD138-positive cells in endometrial biopsies.

Induction of the epithelial-mesenchymal transition in the endometrium by chronic endometritis in infertile patients

Background

The purpose of the present study was to evaluate the relationship between chronic endometritis and the epithelial-mesenchymal transition in the endometrium of infertile patients in the implantation phase.

Methods

Endometrial biopsy specimens from 66 infertility patients were analyzed. The presence of chronic endometritis was investigated by immunostaining for CD138. Immunohistochemical staining for E-cadherin, N-cadherin, Slug, and Snail was performed, and the expression profiles were statistically analyzed according to the presence of chronic endometritis. When the loss of E-cadherin expression and/or the positive expression of N-cadherin was detected, the specimen was considered epithelial-mesenchymal transition-positive. Epithelial-mesenchymal transition-positive cases were also statistically analyzed according to the presence of chronic endometritis. The characteristics of the patients in the epithelial-mesenchymal transition-positive and epithelial-mesenchymal transition-negative groups were compared. The association between variables, including age, body mass index, gravidity, parity, and each causative factor of infertility and epithelial-mesenchymal transition positivity was analyzed.

Results

The rates of the loss of E-cadherin expression, the gain of N-cadherin and epithelial-mesenchymal transition positivity were significantly higher in chronic endometritis patients. The expression of Slug, cytoplasmic Snail, and nuclear Snail was also detected at significantly higher rates in chronic endometritis patients. Chronic endometritis were related to the epithelial-mesenchymal transition.

Conclusion

The epithelial-mesenchymal transition was frequently detected in the endometrium in infertile patients with chronic endometritis. Since the epithelial-mesenchymal transition is associated with chronic endometritis, the epithelial-mesenchymal transition appears to be involved in the alteration of mechanisms of implantation.

Hysteroscopy as An Investigational Operative Procedure in Primary and Secondary Infertility: A Systematic Review

Background

The aim of this study is to review current indications to diagnostic and/or operative hysteroscopy in primary and secondary infertility, as well as to determine its efficacy in improving fertility.

Materials and Methods

We gathered available evidence about the role of hysteroscopy in the management of vari- ous infertility conditions. Literature from 2000 to 2020 that pertained to this topic were retrieved and appropriately selected.

Results

Hysteroscopy does not appear as a first line diagnostic procedure for every clinical scenario. However, its di- agnostic sensitivity and specificity in assessing intrauterine pathology is superior to all other non-invasive techniques, such as saline infusion/gel instillation sonography (SIS/GIS), transvaginal sonography (TVS) and hysterosalpingog- raphy (HSG). Hysteroscopy allows not only a satisfactory evaluation of the uterine cavity but also, the eventual treat- ment of endocavitary pathologies that may affect fertility both in spontaneous and assisted reproductive technology (ART) cycles.

Conclusion

Hysteroscopy, due to its diagnostic and therapeutic potential, should be regarded as a necessary step in infertility management. However, in case of suspected uterine malformation, hysteroscopy should be integrated with other tests [three-dimensional (3D) ultrasound or magnetic resonance imaging (MRI)] for diagnostic confirmation.

Endometrial causes of recurrent pregnancy losses: endometriosis, adenomyosis, and chronic endometritis

Chronic inflammatory processes affecting the endometrium, as encountered in endometriosis, adenomyosis, and chronic endometritis, alter endometrial receptivity. These disorders are associated with early pregnancy losses and possibly recurrent pregnancy losses (RPL). In the cases of endometriosis, other factors associated with the disease also are susceptible of causing miscarriages and possibly RPL, such as an impact of intrapelvic inflammatory processes affecting the oocyte and embryo in case of natural conception. Conversely these latter effects obviously are bypassed in case of assisted reproductive technology. Chronic inflammation of the endometrium in the condition known as chronic endometritis also causes early pregnancy losses and RPL with beneficial effects achieved when specific treatment is undertaken.

Impact of antibiotic therapy on the rate of negative test results for chronic endometritis: a prospective randomized control trial

OBJECTIVE

To compare the rates of negative test results for chronic endometritis (CE) between subjects who did and did not receive antibiotic treatment.

DESIGN

Prospective, single-blind randomized controlled trial.

SETTING

Tertiary hysteroscopic center in a university teaching hospital.

PATIENT(S)

A total of 132 women with CE confirmed with immunohistochemical study with CD138 epitope.

INTERVENTION(S)

Women randomized to antibiotic therapy received oral levofloxacin 500 mg and tinidazole 1,000 mg daily for 14 days. Women randomized to the control group did not receive any treatment. A repeated endometrial biopsy was performed 4 to 8 weeks after the initial biopsy to determine whether CE was still present.

MAIN OUTCOME MEASURE(S)

The rate of negative test results for CE (from positive to negative).

RESULT(S)

The CE rate of negative test results in the treatment group (89.3%) after one course of antibiotic treatment was significantly higher than that in the control group (12.7%). Among subjects who attempted pregnancy, there was no significant difference in ongoing pregnancy rates and miscarriage rates between the treatment arm (43.2%, 5.4%) and the control arm (25.7%, 14.3%). Among subjects randomized, there was also no significant difference in ongoing pregnancy rates and miscarriage rates between the treatment arm (27.1%, 3.4%) and the control arm (16.4%, 9.1%).

CONCLUSION

A course of broad-spectrum oral antibiotic therapy for 14 days is effective in the treatment of CE in >89.8% of cases. However, it is not yet clear whether treatment improved pregnancy outcomes.

CLINICAL TRIAL IDENTIFICATION NUMBER

NCT02648698.

Risk of Recurrent Pregnancy Loss in the Ukrainian Population Using a Combined Effect of Genetic Variants: A Case-Control Study

We assessed the predictive ability of a combined genetic variant panel for the risk of recurrent pregnancy loss (RPL) through a case-control study. Our study sample was from Ukraine and included 114 cases with idiopathic RPL and 106 controls without any pregnancy losses/complications and with at least one healthy child. We genotyped variants within 12 genetic loci reflecting the main biological pathways involved in pregnancy maintenance: blood coagulation (F2, F5, F7, GP1A), hormonal regulation (ESR1, ADRB2), endometrium and placental function (ENOS, ACE), folate metabolism (MTHFR) and inflammatory response (IL6, IL8, IL10). We showed that a genetic risk score (GRS) calculated from the 12 variants was associated with an increased risk of RPL (odds ratio 1.56, 95% CI: 1.21, 2.04, p = 8.7 × 10-4). The receiver operator characteristic (ROC) analysis resulted in an area under the curve (AUC) of 0.64 (95% CI: 0.57, 0.72), indicating an improved ability of the GRS to classify women with and without RPL. Ιmplementation of the GRS approach can help define women at higher risk of complex multifactorial conditions such as RPL. Future well-powered genome-wide association studies will help in dissecting biological pathways previously unknown for RPL and further improve the identification of women with RPL susceptibility.

Quantifying CD138+ cells in the endometrium to assess chronic endometritis in women at risk of recurrent pregnancy loss: A prospective cohort study and rapid review

OBJECTIVE

To determine the value of uterine CD138+ cells, as a marker of chronic endometritis, in predicting subsequent reproductive outcome in women with history of recurrent pregnancy loss.

DESIGN

A prospective longitudinal study.

SETTING

Tertiary specialized clinic.

PATIENTS

Women with history of recurrent pregnancy loss or implantation failure over a 12-months follow-up period.

INTERVENTION

We quantified the CD138+ cells/high powered field (hpf) using immunohistochemistry and image analysis of endometrial biopsies obtained during the secretory stage post ovulation.

MAIN OUTCOME MEASURES

Live birth and subsequent pregnancy loss. We calculated the receiver operator curve for predicting subsequent pregnancy loss and reported using relative risk (RR) and 95% confidence intervals (CI).

RESULTS

We enrolled 344 women of whom 88 became pregnant (88/344, 25.5%). Half of them had a subsequent live birth (47/88, 53%) and the rest lost their pregnancy (41/88, 46%). The median CD138+ score was significantly lower in the live birth group (P < 0.005) and women with a CD138+ score ≥ 16/hpf had a higher risk of subsequent miscarriage (RR 10.0, 95% CI 2.78-36.02). CD138+ cells count showed a good prediction for subsequent pregnancy loss in high-risk women with an area under the curve of 0.75 (95% CI 0.59-0.82, P = 0.01). A cut-off value of 4-6 cells/hpf offered the best predictive accuracy with higher scores predicting worse reproductive outcome. Our findings are limited by the small event rate and the sample size of our cohort.

CONCLUSION

Quantifying CD138+ cells by immunohistochemistry in women with a history of recurrent pregnancy loss is helpful to diagnose chronic endometritis and predict subsequent reproductive outcome.

In women with chronic or subclinical endometritis is hysteroscopy suitable for setting the diagnosis? A systematic review

The role of hysteroscopy in cases of chronic or subclinical endometritis remains uncertain. Reevaluating the clinical relevance of diagnostic hysteroscopic in these cases will improve the level of case in women's health worldwide. The objective of this systematic review was to assess the suitability of hysteroscopy in detecting and diagnosing female patients with chronic or subclinical endometritis, as a first-line diagnostic tool. For this systematic review, five major search engines PubMed, Embase, MEDLINE, Google Scholar, as well as ResearchGate were searched using MeSH (medical subject headings) without language or year restrictions up to November 2019. All types of scientific papers were taken into consideration, with a priority to randomized control trials enrolling women with chronic or subclinical endometritis and compared with standard diagnostic tools such as histology or immunohistochemistry, in order to ensure the efficacy of the method. Risk of bias was assessed using the recommended Cochrane Collaboration criteria. In order to gather more information and data, we have decided to include all the scientific evidence regardless of study design. Data collection and analysis were performed according to PRISMA protocol. Hysteroscopy is an important diagnostic tool in cases of endometritis when accompanied by endometrial samples assessment techniques. In cases of high suspicion endometritis facilitates greater diagnostic accuracy. Hysteroscopy facilitates also the assessment of antibiotic administration efficacy in cases of confirmed endometritis. Micropolyposis, stromal edema or congestion, diffuse or focal hyperemia are the dominant hysteroscopic features that are considered by most studies as suggestive of chronic or subclinical endometritis. The heterogeneity of the included studies presents a high risk of bias as assessed according to Cochrane Collaboration criteria. Hysteroscopy is not suitable as a first-line diagnostic tool in cases of chronic or subclinical endometritis. Further randomized controlled trials need to be conducted in order to define the role of hysteroscopy as a first-line diagnostic tool in cases of chronic or subclinical endometritis.

ED50 of propofol in combination with low-dose sufentanil for intravenous anaesthesia in hysteroscopy

OBJECTIVES

Sufentanil has favourable pharmacodynamic and pharmacokinetic properties as an opioid, and it is usually co-administered with propofol as intravenous anaesthesia for hysteroscopic examination or therapeutic surgery. However, the optimal dosage of propofol when it is co-administered with low-dose sufentanil has not yet been established. This study was designed to find the median effective dose of propofol for intravenous anaesthesia when combined with low-dose sufentanil.

METHODS

Fifty-four patients were enrolled and randomized into two groups in this prospective study. Sufentanil 0.2 μg/kg (Group A) or 0.1 μg/kg (Group B) was given intravenously before speculum placement. The initial propofol dose was set at 2 mg/kg and varied by 0.1 mg/kg according to the sequential allocation up-and-down rule designed by Dixon and Massey. Respiratory depression, duration of initial dose of propofol, total drug quantity administered and recovery time were recorded.

RESULTS

The ED50 of propofol was 1.651 mg/kg (95% CI, 1.561-1.722 mg/kg) in Group A and 1.991 mg/kg (95% CI, 1.902-2.081 mg/kg) in Group B. The ED95 of propofol was 1.827 mg/kg (95% CI, 1.746-2.236 mg/kg) in Group A and 2.153 mg/kg (95% CI, 2.070-2.73 7 mg/kg) in Group B. The initial and total dosage of propofol in Group A were significantly lower than those in Group B, but the incidence of respiratory depression in Group A (26.67%) was significantly higher than that in Group B (4.17%).

CONCLUSION

The ED50 values for propofol when co-administered with low-dose sufentanil for intravenous anaesthesia in hysteroscopy were 1.651 mg/kg (sufentanil 0.2 μg/kg) and 1.991 mg/kg (sufentanil 0.1 μg/kg). (www.chictr.org.cn, registration number: ChiCTR1900021224).