The Diagnosis of Chronic Endometritis in Infertile Asymptomatic Women: A Comparative Study of Histology, Microbial Cultures, Hysteroscopy, and Molecular Microbiology

Am J Obstet Gynecol. 2018 Jun;218(6):602.e1-602.e16. doi: 10.1016/j.ajog.2018.02.012. Epub 2018 Feb 23.


Background: Chronic endometritis is a persistent inflammation of the endometrial mucosa caused by bacterial pathogens such as Enterobacteriaceae, Enterococcus, Streptococcus, Staphylococcus, Mycoplasma, and Ureaplasma. Although chronic endometritis can be asymptomatic, it is found in up to 40% of infertile patients and is responsible for repeated implantation failure and recurrent miscarriage. Diagnosis of chronic endometritis is based on hysteroscopy of the uterine cavity, endometrial biopsy with plasma cells being identified histologically, while specific treatment is determined based on microbial culture. However, not all microorganisms implicated are easily or readily culturable needing a turnaround time of up to 1 week.

Objective: We sought to develop a molecular diagnostic tool for chronic endometritis based on real-time polymerase chain reaction equivalent to using the 3 classic methods together, overcoming the bias of using any of them alone.

Study design: Endometrial samples from patients assessed for chronic endometritis (n = 113) using at least 1 or several conventional diagnostic methods namely histology, hysteroscopy, and/or microbial culture, were blindly evaluated by real-time polymerase chain reaction for the presence of 9 chronic endometritis pathogens: Chlamydia trachomatis, Enterococcus, Escherichia coli, Gardnerella vaginalis, Klebsiella pneumoniae, Mycoplasma hominis, Neisseria gonorrhoeae, Staphylococcus, and Streptococcus. The sensitivity and specificity of the molecular analysis vs the classic diagnostic techniques were compared in the 65 patients assessed by all 3 recognized classic methods.

Results: The molecular method showed concordant results with histological diagnosis in 30 samples (14 double positive and 16 double negative) with a matching accuracy of 46.15%. Concordance of molecular and hysteroscopic diagnosis was observed in 38 samples (37 double positive and 1 double negative), with an accuracy of 58.46%. When the molecular method was compared to microbial culture, concordance was present in 37 samples (22 double positive and 15 double negative), a matching rate of 56.92%. When cases of potential contamination and/or noncultivable bacteria were considered, the accuracy increased to 66.15%. Of these 65 patients, only 27 patients had consistent histological + hysteroscopic diagnosis, revealing 58.64% of nonconcordant results. Only 13 of 65 patients (20%) had consistent histology + hysteroscopy + microbial culture results. In these cases, the molecular microbiology matched in 10 cases showing a diagnostic accuracy of 76.92%. Interestingly, the molecular microbiology confirmed over half of the isolated pathogens and provided additional detection of nonculturable microorganisms. These results were confirmed by the microbiome assessed by next-generation sequencing. In the endometrial samples with concordant histology + hysteroscopy + microbial culture results, the molecular microbiology diagnosis demonstrates 75% sensitivity, 100% specificity, 100% positive and 25% negative predictive values, and 0% false-positive and 25% false-negative rates.

Conclusion: The molecular microbiology method describe herein is a fast and inexpensive diagnostic tool that allows for the identification of culturable and nonculturable endometrial pathogens associated with chronic endometritis. The results obtained were similar to all 3 classic diagnostic methods together with a degree of concordance of 76.92% providing an opportunity to improve the clinical management of infertile patients with a risk of experiencing this ghost endometrial pathology.

Keywords: bacterial pathogens; chronic endometritis; endometrial microbiome; histology; hysteroscopy; microbial culture; molecular microbiology diagnosis; next-generation sequencing; real-time polymerase chain reaction.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Asymptomatic Infections
  • Bacterial Infections / diagnosis*
  • Bacterial Infections / microbiology
  • Bacterial Infections / pathology
  • Biopsy
  • Chlamydia Infections / diagnosis
  • Chlamydia Infections / microbiology
  • Chlamydia Infections / pathology
  • Chlamydia trachomatis / genetics
  • Chronic Disease
  • Culture Techniques
  • DNA, Bacterial / analysis*
  • Endometritis / complications
  • Endometritis / diagnosis*
  • Endometritis / microbiology
  • Endometritis / pathology
  • Endometrium / microbiology
  • Endometrium / pathology*
  • Enterococcus / genetics
  • Escherichia coli / genetics
  • Escherichia coli Infections / diagnosis
  • Escherichia coli Infections / microbiology
  • Escherichia coli Infections / pathology
  • Female
  • Gardnerella vaginalis / genetics
  • Gonorrhea / diagnosis
  • Gonorrhea / microbiology
  • Gonorrhea / pathology
  • Gram-Positive Bacterial Infections / diagnosis
  • Gram-Positive Bacterial Infections / microbiology
  • Gram-Positive Bacterial Infections / pathology
  • High-Throughput Nucleotide Sequencing
  • Humans
  • Hysteroscopy*
  • Infertility, Female / complications
  • Klebsiella Infections / diagnosis
  • Klebsiella Infections / microbiology
  • Klebsiella Infections / pathology
  • Klebsiella pneumoniae / genetics
  • Middle Aged
  • Mycoplasma Infections / diagnosis
  • Mycoplasma Infections / microbiology
  • Mycoplasma Infections / pathology
  • Mycoplasma hominis / genetics
  • Neisseria gonorrhoeae / genetics
  • Pathology, Molecular
  • Plasma Cells / pathology
  • Real-Time Polymerase Chain Reaction
  • Sensitivity and Specificity
  • Sequence Analysis, DNA
  • Staphylococcal Infections / diagnosis
  • Staphylococcal Infections / microbiology
  • Staphylococcal Infections / pathology
  • Staphylococcus / genetics
  • Streptococcal Infections / diagnosis
  • Streptococcal Infections / microbiology
  • Streptococcal Infections / pathology
  • Streptococcus / genetics
  • Young Adult


  • DNA, Bacterial