Diagnostic Accuracy of Hysteroscopy for Chronic Endometritis in Reproductive-Age and Infertile Women: A Systematic Review and Latent Class Meta-Analysis

Federico Pérez Milán; Miguel Caballero Campo; José Antonio Domínguez Arroyo; María Carrera Roig; Enrique Moratalla Bartolomé; Sergio Haimovich; Enrique Pérez de la Blanca; Gorka Barrenetxea Ziarrusta; José Manuel Puente Águeda; Juan Luis Alcázar Zambrano; Jose Carugno; Spanish Fertility Society Special Interest Group on Benign Organic Reproductive Disorders

doi:10.1016/j.jmig.2026.02.021

Diagnostic Accuracy of Hysteroscopy for Chronic Endometritis in Reproductive-Age and Infertile Women: A Systematic Review and Latent Class Meta-Analysis

J Minim Invasive Gynecol. 2026 Feb 11:S1553-4650(26)00128-7. doi: 10.1016/j.jmig.2026.02.021. Online ahead of print.

Authors

Affiliations

¹ Reproductive Medicine Unit (Dr Pérez Milán), Department of Obstetrics and Gynecology, Gregorio Marañón General University Hospital, Madrid, Spain; Gregorio Marañón Health Research Institute (Drs Pérez Milán and Caballero Campo), Madrid, Spain; Complutense University (Drs Pérez Milán and Carrera Roig), Madrid, Spain. Electronic address: federicom.perez@salud.madrid.org.
² Gregorio Marañón Health Research Institute (Drs Pérez Milán and Caballero Campo), Madrid, Spain; Repromed Dublin Clinic (Dr Caballero Campo), Dublin, Ireland.
³ Instituto Extremeño de Reproducción Asistida (Dr Domínguez Arroyo), Badajoz, Spain; University of Extremadura (Dr Domínguez Arroyo), Badajoz, Spain; Jesús Usón Minimally Invasive Surgery Center (Dr Domínguez Arroyo), Cáceres, Spain.
⁴ Complutense University (Drs Pérez Milán and Carrera Roig), Madrid, Spain; Reproductive Medicine Unit (Dr Carrera Roig), Department of Obstetrics and Gynecology, Doce de Octubre University Hospital, Madrid, Spain; Reproductive Medicine Unit (Dr Carrera Roig), HLA Moncloa University Hospital, European University of Madrid, Madrid, Spain.
⁵ Department of Obstetrics and Gynecology (Dr Moratalla Bartolomé), Ramón y Cajal University Hospital, Madrid, Spain; Department of Obstetrics and Gynecology (Dr Moratalla Bartolomé), HM Montepríncipe University Hospital, Madrid, Spain.
⁶ Gynecology Department (Dr Haimovich), Adelson Medical School, Ariel University, Ariel, Israel; Reproductive Surgery and Endoscopy Unit (Dr Haimovich), Embriogyn Center for Reproductive Medicine, Tarragona, Spain.
⁷ Reproductive Medicine Unit (Dr Pérez de la Blanca), Department of Obstetrics and Gynecology, Hospital Quironsalud, Málaga, Spain.
⁸ Reproducción Bilbao Clinic (Dr Barrenetxea Ziarrusta), Bilbao, Spain; Basque Country University (Dr Barrenetxea Ziarrusta), Bilbao, Spain.
⁹ Department of Obstetrics and Gynecology (Dr Puente Águeda), Doce de Octubre University Hospital, Madrid, Spain; IVIRMA Clinic (Dr Puente Águeda), Madrid, Spain.
¹⁰ Gynecological Ultrasonography Unit (Dr Alcázar Zambrano), Department of Obstetrics and Gynecology, Hospital Quironsalud, Málaga, Spain; University of Navarra (Dr Alcázar Zambrano), Pamplona, Spain.
¹¹ Miller School of Medicine (Dr Carugno), Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Miami, Florida.

PMID: 41688012
DOI: 10.1016/j.jmig.2026.02.021

Abstract

Objective: To evaluate the diagnostic accuracy of hysteroscopy for chronic endometritis (CE) in reproductive-aged women, including those with infertility or recurrent pregnancy loss, considering histopathological, immunohistochemical, and microbiological tests as imperfect reference standards through a Bayesian latent class meta-analysis.

Data sources and method of study selection: We included peer-reviewed diagnostic accuracy studies, cohort studies, and case series that assessed hysteroscopy as the index test for CE. Eligible studies applied histopathological, immunohistochemical, or microbiological reference standards to endometrial, endocervical, or vaginal samples, providing sufficient quantitative data. Searches across common databases and registries up to October 1st, 2025, were not restricted by language. Study quality was assessed using QUADAS-2.

Tabulation and integration: Pooled estimates of sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios (LR) were obtained using an imperfect-standards Bayesian latent class meta-analysis approach. Subgroup and sensitivity analyses were performed regarding the profile of the studied populations and the risk of bias within and across the studies.

Results: The 28 included studies (12 diagnostic accuracy, 5 cohort, 11 case series) yielded pooled hysteroscopy results of 0.816 sensitivity (95% CI: 0.728-0.882), 0.806 specificity (0.729-0.871), and a DOR of 18.895 (9.364-39.832). Hematoxylin-eosin staining was the most accurate reference standard. Subgroup and sensitivity analyses confirmed results consistency across reproductive-disorder populations and lower-bias studies, with a low estimated risk of reporting bias.

Conclusion: Hysteroscopy demonstrates high diagnostic performance for CE when compared against imperfect reference standards. Despite model-based limitations, evidence supports hysteroscopy as a reliable primary diagnostic tool in clinical assessment and treatment planning.

Registration: PROSPERO registration number: CRD420251087545.

Keywords: Bacterial infection; CD138; Chronic endometritis; Diagnostic accuracy; Hysteroscopy; Immunohistochemistry.

Publication types

Review