Chronic endometritis and altered embryo implantation: a unified pathophysiological theory from a literature systematic r
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REVIEW
Chronic endometritis and altered embryo implantation: a unified pathophysiological theory from a literature systematic review Giovanni Buzzaccarini 1 & Amerigo Vitagliano 1 & Alessandra Andrisani 1 & Carla Mariaflavia Santarsiero 2 & Rossana Cicinelli 2 & Claudia Nardelli 2 & Guido Ambrosini 1 & Ettore Cicinelli 2 Received: 25 June 2020 / Accepted: 22 September 2020 # The Author(s) 2020
Abstract Purpose Chronic endometritis (CE) is a frequent hysteroscopic and histological finding which affects embryo transfer implantation during IVF-ICSI cycles. In particular, CE impairs proper decidualization and, subsequently, implantation. Although this correlation has been clearly clarified, a pathophysiological explanation assembling all the studies performed has not been elucidated yet. For this reason, we have structured a systematic review considering all the original articles that evaluated a pathological element involved in CE and implantation impairment. Methods The authors searched electronic databases and, after screening, collected 15 original articles. These were fully scanned and used to create a summary pathway. Results CE is primarily caused by infections, which lead to a specific cytokine and leukocyte pattern in order to prepare the uterus to fight the noxa. In particular, the immunosuppression requested for a proper semi-allogenic embryo transfer implantation is converted into an immunoreaction, which hampers correct embryo implantation. Moreover, endometrial vascularization is affected and both irregular vessel density and luminal thickening and thrombosis reduce what we have first identified as endometrial flow reserve. Finally, incorrect uterine wave propagation could affect embryo contact with decidua. Conclusion This is the first summary of evidence on CE pathophysiology and its relationship with infertility. Understanding the CE pathophysiology could improve our knowledge in embryo transfer success. Keywords Chronic endometritis . Infertility . Pathophysiology . IVF . Embryo transfer . Recurrent pregnancy failures . Recurrent pregnancy loss
Introduction Chronic endometritis (CE) is a persistent inflammatory disorder of the endometrial lining, characterized by superficial endometrial edematous change, high stromal cell density, dissociated maturation between epithelium and stroma, and infiltration of endometrial stromal plasmacytes (ESPCs) [1–5]. The pathogenesis of CE seems to be related to a qualitative and quantitative alteration of endometrial microbioma, with
* Giovanni Buzzaccarini [email protected] 1
Gynecological Clinic, UOS Medically Assisted Procreation, University of Padova, via Nicolò Giustiniani 3, Padova, Italy
2
Second Unit of Obstetrics and Gynecology, Department of Biomedical Sciences and Human Oncology, University of Bari “A. Moro”, Piazza G. Cesare 11, Bari, Italy
the abnormal proliferation of different types of microorganisms, mainly gram-negative and intracellular bacteria (i.e., Enterococcus faecalis, Mycoplasma, Ureaplasma, Chlamydia, Escherichia coli, a
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