The demographic characteristics of the study population that underwent an IVF procedure are displayed in Table 1. The age, the provenance, the obstetrical history, the normal hysteroscopic aspect were not significantly different between groups. Regarding the indication for the IVF procedures, diminished ovarian reserve was encountered more frequently in patients without chronic endometritis, but we consider this an incidental aspect.
Table nr. 1: Demographic characteristics of the study population - patients with positive and negative diagnosis for chronic endometritis
Variable | With chronic endometritis (n = 57) | Without chronic endometritis (n = 58) | p (statistical significance) |
Age (years) – average (± SD) | 35,08 (± 4,6) | 35,84 (± 5,0) | 0,4010 |
Provenance – U (percentage - %) | 38 (66,67%) | 36 (62,07%) | 0,7490 |
Previous abortion- Yes (percentage - %) | 12 (21,05%) | 15 (25,86%) | 0,6977 |
Ectopic pregnancy – Yes (percentage - %) | 4 (7,01%) | 1 (1,72%) | 0,3501 |
Birth – Yes (percentage - %) | 3 (5,26%) | 2 (3,45%) | 0,9841 |
Hysteroscopic aspects – normal (percentage - %) | 35 (61.40%) | 34 (58.62%) | 0.9091 |
IVF indication (%) Low AMH PCOS Tubal Advanced maternal age FF MF Unknown | 3 (5,26%) 0 (0%) 11 (11,29%) 13 (22,80%) 14 (24,56%) 16 (28,07%) 12 (21,05%) | 14 (24,14%) 2 (3,45%) 7 (12,07%) 7 (12,07%) 15 (25,86%) 15 (25,86%) 12 (20,69%) | 0,0096 0,4833 0,4179 0,2030 0,9568 0,9548 0,8559 |
SD = standard deviation; U = urban; R = rural; IVF = in vitro fertilization; Anti mullerian hormone (AMH) = diminished ovarian reserve; PCOS = polycystic ovarian syndrome; FF = feminine factor; MF = masculine factor |
Chronic endometritis prevalence according to the diagnosis criteria is 49.6%. After the diagnosis patients were divided in the oral antibiotic therapy group (OAB) and the intrauterine antibiotic infusion group (IAI). The division of patients according to the treatment option gave us the following results in clinical and demographic characteristics (table no 2):
Table no 2: Demographic and clinical characteristics for the 2 groups of patients according to the treatment option for chronic endometritis
Characteristics | Treatment OAB (n = 24) | Treatment IAI (n = 28) | p (statistical semnification) |
Age (years) – average (± DS) | 34,92 (± 4,2) | 35,14 (± 5,0) | 0,8629 |
Provenience – U (percentage - %) | 14 (58,33%) | 19 (67,86%) | 0,6729 |
After treatment – negative (%) | 11 (45,83%) | 25 (89,29%) | 0,0020 |
IVF results (%) Ongoing pregnancy Abortion Birth | 5 (20,83%) 3 (12,50%) 1 (4,17%) | 13 (46,43%) 2 (7,14%) 0 (0,00%) | 0,1007 0,8560 0,9379 |
OAB = oral antibiotic; IAI = Intrauterine antibiotic infusion; SD = standard deviation; U = urban; R = rural; IVF = in vitro fertilization; |
Among oral antibiotic group, 11 patients (45.83%) experienced CE resolution after the triple antibiotic therapy. Among intrauterine infusion group, 25 patients (89.29%) presented negative controls (p 0,0020). The efficiency of the treatment in producing negative CD 138 testing was significantly higher for the patients treated by the intrauterine antibiotic infusion: RR = 1,9481 (IC95%: 1,23 − 3,06), p = 0,0039 with NNT = 2,301 (IC95%: 1,52 − 4,71).
The hysteroscopic aspects of chronic endometritis are considered to be the classical strawberry pattern but also hemorrhagic spots, focal and generalized hyperemia, pale and edematous mucosa and the presence of micro-polyps as shown in the figure bellow (Figure no. 2).
Figure no. 2: Hysteroscopy findings in chronic endometritis. A. Generalized hyperemia. B. Pale mucosa with polyp. C. Pale mucosa with hemorrhagic spots. D. Strawberry aspect. E. Focal hyperemia. F. Micro-polyps
The histological evaluation was done by identification of one or more plasma cells in the endometrial stroma. Presence of CD138 positive plasma cells were confirmed by brown colored membranes and cytoplasm [22][28]. (Figure no. 3)
Figure no. 3: a. Fragment of the endometrial mucosa showing proliferative endometrial glands with an edematous stroma. It is difficult to identify plasma cells in HE staining. Most inflammatory cells are lymphocytes (HE 100X). b. Fragment of the endometrial mucosa that shows a positive reaction to CD138 by the IHC (immunohistochemical) technique. Positive control is represented by glandular epithelial cells. In the stroma there are cells with a positive expression (100x). c. The image shows the expression of the positive control (glands) for the CD138 reaction and in the stroma there are several cells with surface marker expression, with equal epithelial intensity of CD138 (plasma cells). Most stromal cells are negative. 200X
The normal hysteroscopic aspect had a similar prevalence in patients with the immunohistochemical positive CD 138 as in the group that tested negative at the immunohistochemical CD 138 biopsy for chronic endometritis.
The antibiotic treatment had no significant adverse effects either orally or in uterine infusion and the hysteroscopic procedure had no complications including no bleeding nor infections.