Unveiling the silver lining: a narrative review of clinical evaluation and management of chronic endometritis and its impact on fertility

Chronic endometritis (CE) is a challenging clinical diagnosis that is often encountered in patients with conditions impacting fertility. Evaluation for CE is somewhat controversial, largely because of a lack of consensus regarding appropriate screening methods and benefits of treatment. Testing is relatively invasive, requiring direct endometrial sampling with histologic evaluation for the presence of plasma cells, a key feature of CE. However, other testing methods have been proposed, including, more recently, microbiome testing. Moreover, defined histologic criteria are currently lacking with significant variability in practice patterns regarding diagnosis. We seek to comprehensively review the literature and examine what is known regarding the pathophysiology, histologic findings, clinical presentation, and treatment of CE. We further examine the association of CE and its implications for patients with conditions impacting fertility, including infertility, recurrent pregnancy loss, recurrent implantation failure, and endometriosis. On the basis of the evidence, we aim to better define when to initiate evaluation for CE and to determine indications for treatment. We also provide a clinical algorithm for CE screening and management.