Chronic endometritis is a persistent inflammation of the endometrium, meaning the lining that covers the inside of the uterus. Unlike acute forms, which may cause more obvious symptoms, this form can develop discreetly, sometimes without pain, fever or clear gynecological signs. For this reason, it may only be discovered during an evaluation for infertility, difficult implantation or repeatedly unsatisfactory results before an embryo transfer.

In a fertility pathway, the endometrium is not seen only as a “place” where the embryo may implant, but as an active tissue with a role in receptivity, vascularization, local immune response and support for the beginning of pregnancy. When there is suspicion that the uterus or uterine lining may influence the chances of implantation, the doctor may recommend additional investigations, including evaluation of the uterine cavity through hysteroscopy, depending on your medical history.

It is important to know that chronic endometritis does not automatically mean infertility and does not explain all cases of difficult implantation. However, in certain clinical contexts, it may become a factor worth checking carefully, especially when other tests appear normal, but pregnancy is delayed or embryo transfers do not progress as expected.

What Chronic Endometritis Is and Why It May Go Unnoticed

Chronic endometritis is a long-term inflammation of the endometrium. Most often, it is associated with the presence of inflammatory cells in the endometrial tissue, and the diagnosis is not established based on symptoms alone. Some patients may experience abnormal bleeding, pelvic discomfort, altered discharge or mild pain, but many do not notice anything specific.

This lack of obvious signs is precisely what can make chronic endometritis difficult to identify. Apparently normal menstruation, absence of pain or lack of recent gynecological infections do not completely exclude persistent endometrial inflammation. In reproductive medicine, suspicion usually appears by correlating several elements: reproductive history, investigation results, the appearance of the endometrium, the previous evolution of treatments and possible implantation failures.

The causes may vary. Sometimes, inflammation may be linked to bacterial infections, previous intrauterine procedures, changes in the genital microbiome or other local inflammatory processes. In other situations, the exact cause is not easy to demonstrate. For this reason, the approach must remain cautious: not every suspicion becomes a diagnosis, and the diagnosis must be confirmed through appropriate methods, not assumed only based on symptoms.

How Chronic Endometritis May Influence Fertility

The connection between chronic endometritis and fertility is discussed especially in the context of endometrial receptivity. For a pregnancy to begin, it is not enough to consider ovulation, semen analysis or embryo quality separately. The endometrium must be in a suitable state for implantation, and chronic inflammation may alter the local environment where the embryo should attach.

This connection should not be interpreted rigidly. Chronic endometritis is not the only explanation for infertility and is not present in all cases of implantation failure. However, when there are unsuccessful embryo transfers, recurrent pregnancy losses or difficult endometrial preparation, the doctor may also consider this possibility, together with other uterine, hormonal, genetic, immunological or embryological factors.

Endometrial Inflammation and Endometrial Receptivity

Endometrial receptivity describes the ability of the uterine lining to allow embryo implantation during a favorable biological window. Normally, the endometrium goes through coordinated changes in each menstrual cycle, under the influence of hormones. Thickness, structure, vascularization and the local tissue response all matter together.

In chronic endometritis, inflammation may disturb this balance. Changes may appear in local immune cells, vascularization and the signals that support implantation. These mechanisms are not always visible on ultrasound and cannot be inferred only from endometrial thickness. In some cases, an endometrium with an apparently acceptable appearance may have a microscopic inflammatory issue.

When It May Become Relevant Before Embryo Transfer

Before an embryo transfer, the goal is for the endometrium to be as well prepared as possible to receive the embryo. If there are suspicions related to inflammation, polyps, adhesions, infections or other intrauterine changes, preparation is not limited only to hormonal treatment. A broader evaluation may be necessary, adapted to your medical history.

For patients undergoing IVF, the question is not only “when is the transfer performed?”, but also whether there are suitable endometrial conditions for transfer. For this reason, recommendations regarding preparation before embryo transfer must distinguish between useful measures, common myths and medical investigations that can actually change the treatment approach.

When Chronic Endometritis May Be Worth Investigating

Not all patients dealing with infertility automatically need investigations for chronic endometritis. The evaluation must be decided by the doctor, depending on the overall case. In general, suspicion may be more relevant when there is infertility without a clear cause after basic investigations, repeated implantation failures, recurrent pregnancy losses or a history of infections, intrauterine procedures or pelvic inflammation.

It may also be considered when the endometrium does not respond properly during transfer preparation or when there are contradictory results between investigations. For example, ultrasound may show an acceptable thickness, but the clinical history may suggest that a more detailed evaluation of the uterine cavity or endometrial tissue is needed.

Signs that may guide the discussion with the doctor include:

• bleeding between periods or unusually altered periods;
• persistent vaginal discharge, especially if accompanied by discomfort;
• recurrent pelvic pain without a clear explanation;
• repeated unsuccessful embryo transfers;
• repeated pregnancy losses;
• history of genital infections, curettage, uterine procedures or complicated births.

These situations do not confirm the diagnosis, but they may justify a more careful medical discussion. Chronic endometritis should be viewed as a possible piece in a clinical puzzle, not as a quick conclusion.

“You deserve to be listened to, seen, treated with respect and supported throughout every stage of life.”

Andreas Vythoulkas

Specialist in Obstetrics and Gynecology

How the Diagnosis Is Established and What May Follow After the Result

The diagnosis of chronic endometritis should not be established only through symptoms or through a general assumption. In practice, the doctor may recommend evaluation of the uterine cavity, endometrial biopsy and histological analysis, sometimes with specific markers to identify inflammatory cells. The choice of investigations depends on the clinical context, previous treatments and the immediate objective: achieving pregnancy naturally, preparing for IVF or optimizing an embryo transfer.

The Role of Hysteroscopy and Endometrial Biopsy

Hysteroscopy allows direct visualization of the uterine cavity. Through this investigation, certain changes may be observed, such as micropolyps, areas of redness, edema or aspects suggestive of inflammation. At the same time, hysteroscopy may also identify other causes that can affect implantation, such as polyps, synechiae or certain abnormalities of the uterine cavity.

However, for confirming chronic endometritis, the visual appearance is not always sufficient. In many cases, endometrial biopsy and laboratory analysis provide the decisive information. The doctor may recommend these investigations when the result can influence the treatment plan or the optimal timing for transfer.

Why Treatment Must Be Decided Individually

If chronic endometritis is confirmed, treatment is established depending on the cause, the result, the patient’s history and the reproductive plan. In some cases, antibiotic treatment may be recommended. In other situations, additional investigations, repeat biopsy or postponing the transfer until the inflammation is clarified may be necessary.

It is essential that treatment is not started without medical recommendation. Empirical antibiotic use, without a clear diagnosis, may be unnecessary and may create other problems, including imbalances of the vaginal flora or bacterial resistance. In fertility care, a treatment is useful when it responds to a real indication, not when it is used preventively without criteria.

For patients undergoing an In Vitro Fertilization pathway, endometrial evaluation is part of a broader strategy. The embryo, uterus, age, ovarian reserve, medical history and response to treatments must be analyzed together. Chronic endometritis may matter, but it should not be isolated from the rest of the clinical picture.

Frequently Asked Questions

Can chronic endometritis exist without symptoms?
Yes, chronic endometritis may be asymptomatic or may cause nonspecific manifestations, such as irregular bleeding, pelvic discomfort or altered discharge. The absence of symptoms does not exclude the diagnosis, especially when there is infertility, difficult implantation or repeated pregnancy losses.

Does chronic endometritis automatically mean that you cannot get pregnant?
No. Chronic endometritis does not automatically mean infertility and does not necessarily block pregnancy from occurring. However, in certain cases, endometrial inflammation may affect endometrial receptivity and may be a factor worth investigating.

How is chronic endometritis confirmed?
Confirmation is usually made through medical evaluation, possibly hysteroscopy and endometrial biopsy with histological analysis. The doctor decides which investigations are appropriate depending on your history and the reason why inflammation is suspected.

Is it always treated with antibiotics?
Not always. Treatment depends on the investigation results, severity, clinical context and reproductive plan. Antibiotics may be recommended in some cases, but they should not be taken without diagnosis and medical indication.

May embryo transfer need to be postponed?
Yes, sometimes the doctor may recommend postponing embryo transfer if there is suspicion or confirmation of endometrial inflammation that needs to be treated or reassessed. The decision is made individually, depending on the investigation results and the IVF strategy.

Can chronic endometritis return after treatment?
In some cases, inflammation may persist or recur, especially if there are favoring factors. For this reason, the doctor may recommend reassessment before continuing the reproductive plan, especially in cases with a history of repeated implantation failures.

Why Choose Genesis Athens for the Evaluation of Chronic Endometritis and Fertility

The evaluation of chronic endometritis in the context of fertility requires an integrated approach. It is not enough to analyze a single result, isolated from your medical history. At Genesis Athens, investigations are integrated into a coherent clinical pathway, in which the endometrium, uterine cavity, ovarian reserve, embryo quality and reproductive history are interpreted together.

This approach is especially important when pregnancy does not occur, when the usual investigations appear normal or when preparation for transfer raises additional questions. In such situations, the objective is not to look for forced explanations, but to identify those medical details that may realistically and responsibly change the treatment approach.

Genesis Athens supports a careful, staged medical evaluation adapted to each case. Before recommending a treatment or a new transfer, the medical team can assess whether additional endometrial investigations are needed, whether there are uterine factors that should be corrected and whether the chosen timing for transfer is appropriate. For patients undergoing assisted reproduction, this clarity can make the difference between a rushed decision and a well-founded medical plan.

Contact a specialist

Talk to a specialist about
chronic endometritis

If you have questions about chronic endometritis or are concerned about your fertility, our patient support team is here to offer the guidance and support you need.

Talk to a specialist now

Sources:

• ESHRE – Good Practice Recommendations on Recurrent Implantation Failure
• ESHRE / Human Reproduction Open – Recurrent Implantation Failure Recommendations
• ASRM – Recurrent Pregnancy Loss: Committee Opinion
• Fertility and Sterility – Chronic Endometritis and Recurrent Implantation Failure
• PMC – Chronic Endometritis and Reproductive Failure Review