Endometritis — Diagnosis and Treatment Basics

Key Takeaways

• Endometritis (especially chronic endometritis) can significantly reduce implantation and IVF success.
• The most accurate test is CD138 immunohistochemistry with culture or molecular PCR.
• Symptoms are often absent—most cases are diagnosed due to IVF failures.
• Treatment is typically antibiotics for 10–14 days, with a repeat biopsy to confirm cure.
• Treating endometritis can dramatically improve embryo transfer outcomes.

Endometritis is one of the most overlooked but highly treatable uterine issues affecting fertility and IVF outcomes. Because it often presents with no symptoms, many patients only discover it after repeated implantation failures or unexplained thin lining. Understanding the diagnosis and treatment can help restore a receptive uterine environment and significantly increase the likelihood of a successful pregnancy.

What Is Endometritis?

Endometritis is inflammation or infection of the endometrial lining. It exists in two forms:

Acute Endometritis

• Usually associated with infection symptoms
• Common after miscarriage, delivery, or procedures
• Presents with fever, pain, discharge

Chronic Endometritis

• Subtle, often asymptomatic
• Found in 30–56% of women with recurrent implantation failure
• Caused by low-grade bacterial imbalance
• Affects endometrial receptivity, repair, and immune balance

Why It Matters for IVF

Chronic endometritis can impact fertility by:

Disrupting Implantation

Inflammation interferes with adhesion molecules needed for embryo attachment.

Altering the Immune Environment

Abnormal plasma cells disrupt local immunity and embryo acceptance.

Reducing Lining Quality

Patients may experience:

• Thin lining
• Irregular vascularity
• Delayed trilaminar pattern

Increasing Risk of Miscarriage

Chronic infection can impair the early embryo environment.

How Endometritis Is Diagnosed

1. CD138 Biopsy (Gold Standard)

• Detects plasma cells (hallmark of chronic endometritis)
• Most reliable and widely used
• Done during mid-luteal phase or follicular phase (clinic dependent)

2. Endometrial Culture

• Identifies specific bacteria
• Helps tailor antibiotic treatment

3. Molecular PCR / NGS

• Detects DNA of pathogens
• Useful when culture is negative but suspicion remains

4. Hysteroscopy

Findings may include:

• Micropolyps
• Edema
• Pale endometrium

Often used as a supportive diagnostic tool.

Treatment Options

1. Antibiotics (First-Line)

Common regimens include:

• Doxycycline for 14 days
• Ciprofloxacin + Metronidazole for mixed bacteria
• Tailored antibiotics if culture-guided

2. Repeat Biopsy

Necessary in many cases to confirm resolution before embryo transfer.

3. Adjunctive Therapies

Used in persistent cases:

• Probiotics
• Anti-inflammatory support
• Estradiol priming to help endometrial regeneration

Case Study

Priya, 34, had two failed FETs with good PGT-A embryos. Her lining appeared normal, but her doctor recommended a CD138 biopsy before the next cycle.
The biopsy detected chronic endometritis. After 14 days of antibiotics and a repeat biopsy confirming clearance, she proceeded with a programmed FET.
She conceived in that cycle and delivered a healthy baby girl.

Testimonials

1. Aditi, 39

“I never had symptoms, so I was shocked to learn I had endometritis. Treating it made all the difference in our next IVF round.”

2. Elena, 32

“The biopsy was quick, and I’m grateful my doctor didn’t skip it. My lining improved immediately after treatment.”

3. Meera, 41

“After years of failed cycles, endometritis was the missing puzzle piece. Once treated, I finally saw a positive pregnancy test.”

Expert Quote

“Chronic endometritis is a silent disruptor of implantation. A simple biopsy and targeted treatment can transform IVF outcomes.” — Dr. Rashmi Gulati

Related Links 

• Fresh vs FET — Matching to Uterine Health
• Pain vs Fertility — Different Problems, Different Plans
• Thin Lining — What Helps and What Doesn’t
• Cervical Factors — When Access Is the Issue

Glossary

• CD138 — A marker used to detect plasma cells in endometrial tissue.
• Chronic Endometritis — Long-term inflammation of the uterine lining caused by low-grade infection.
• Biopsy — Tissue sampling for microscopic analysis.
• PCR (Polymerase Chain Reaction) — Technique to detect bacterial DNA.
• Micropolyps — Tiny polyps often seen on hysteroscopy, suggesting infection.
• Receptivity — The endometrium’s readiness to accept an embryo.

FAQ)

Q. What are the most common symptoms of chronic endometritis?

Ans. Most women have no symptoms, which is why it easily goes undetected. Some may experience spotting, pelvic discomfort, or unusual discharge, but these signs are nonspecific. Because the condition is silent, many cases are found only after recurrent implantation failure.

Q. How does chronic endometritis affect IVF success?

Ans. It alters the endometrial immune environment and disrupts implantation signals. Studies show that treating chronic endometritis can significantly increase implantation and live birth rates, especially in patients using PGT-A embryos.

Q. Is CD138 biopsy necessary for everyone attempting IVF?

Ans. Not always, but it is highly recommended in:

• Recurrent implantation failure
• Recurrent pregnancy loss
• Thin lining
• Unexplained inflammation on ultrasound
  Because it’s simple, inexpensive, and highly informative, many clinics use it routinely.

Q. Can hysteroscopy diagnose endometritis on its own?

Ans. It can show suggestive features like micropolyps or edema, but it cannot confirm the diagnosis without biopsy. Hysteroscopy should be combined with CD138 testing.

Q. Do antibiotics always cure chronic endometritis?

Ans. Most cases resolve after a 10–14-day course, but up to 20–30% may require a second round of antibiotics or culture-guided treatment. Persistent cases benefit from probiotics and anti-inflammatory support.

Q. Should I delay my embryo transfer until the infection is cleared?

Ans. Yes. Transferring during active endometritis increases the risk of implantation failure and miscarriage. A cured lining ensures the highest chance of success.

Q. How long after treatment should I repeat the biopsy?

Ans. Typically 2–4 weeks after completing antibiotics. This allows tissue to heal and inflammation to normalize.

Q. Can chronic endometritis cause thin lining?

Ans. Yes. Inflammation disrupts vascular growth and tissue regeneration, leading to weak or delayed lining development. Clearing the infection often improves thickness and pattern.

Q. Is endometritis the same as endometriosis?

Ans. No. Endometritis is infection/inflammation inside the uterus, while endometriosis is the presence of endometrial-like tissue outside the uterus. They are unrelated but can coexist.

Q. Can lifestyle or diet help treat or prevent endometritis?

Ans. While antibiotics are the main treatment, overall vaginal and gut health support—through probiotics, avoiding unnecessary douching, and balanced nutrition—can help maintain healthy microbial balance.

Q. Can endometritis return after treatment?

Ans. It can recur, especially if the underlying bacterial imbalance persists. In IVF patients, repeat testing before transfer ensures the infection has not returned.

Q. Does treating endometritis improve miscarriage rates?

Ans. Yes. Clearing chronic infection can significantly reduce biochemical losses and early miscarriages by restoring a healthy implantation environment.