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Bedeutung der chronischen Endometritis bei rezidivierendem Implantationsversagen und wiederholten Fehlgeburten

Relevance of chronic endometritis in recurrent implantation failure and recurrent miscarriage

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Gynäkologische Endokrinologie Aims and scope

Zusammenfassung

Hintergrund

Aufgrund der häufig nicht zu identifizierenden Ursachen stellen rezidivierendes Implantationsversagen und wiederholte Fehlgeburten sowohl für die Patientinnen als auch für die behandelnden Ärztinnen und Ärzte frustrierende Situationen dar. Neben Faktoren des Embryos werden endometriale Auffälligkeiten als ursächliche Risikofaktoren diskutiert, wobei in den letzten Jahren die chronische Endometritis (CE) in den Fokus des wissenschaftlichen Interesses gerückt ist.

Zielsetzung

Der Beitrag soll einen Überblick über Klinik, Pathophysiologie, Diagnostik und mögliche Therapieoptionen hinsichtlich der CE bei rezidivierendem Implantationsversagen und wiederholten Fehlgeburten geben.

Ergebnisse

Studien weisen darauf hin, dass eine CE über verschiedene Mechanismen negative Effekte auf die Implantation und Entwicklung in der (Früh‑)Schwangerschaft entfaltet, unter anderem durch Beeinflussung der Zytokinsekretion und eine veränderte Zusammensetzung der Lymphozytensubpopulationen im Endometrium. Der immunhistochemische Nachweis von CD138-positiven Plasmazellen im Endometriumbiopsat hat sich als Goldstandard der Diagnostik etabliert. Es besteht jedoch noch kein Konsens über die exakten Diagnosekriterien, woraus die hohen Schwankungen in den Angaben der CE-Prävalenz bei diesem Patientenkollektiv von etwa 10 bis 50 % resultieren könnten. Eine erfolgreiche Therapie gelingt mit Antibiotika, was sich sowohl histologisch durch eine Beseitigung der Plasmazellen als auch klinisch durch eine höhere Implantations‑, Schwangerschafts- und Lebendgeburtenrate nachweisen lässt.

Schlussfolgerung

Die Daten zur Diagnostik und Therapie einer CE bei Patientinnen mit rezidivierendem Implantationsversagen und wiederholten Fehlgeburten sind vielversprechend. Die Bestimmung exakter Diagnosekriterien und die Behandlung von Patientinnen mit Persistenz einer CE trotz antibiotischer Therapie stellen besondere Herausforderungen dar. Weitere randomisierte, idealerweise placebokontrollierte, prospektive Studien mit adäquater Fallzahl werden in den nächsten Jahren Ergebnisse liefern, sodass der Stellenwert einer CE weiter gestärkt werden könnte.

Abstract

Background

Due to causes which frequently cannot be identified, recurrent implantation failure and recurrent miscarriages are frustrating situations for both patients and treating physicians. In addition to embryonic factors, endometrial causes are discussed as potential risk factors, with chronic endometritis (CE) coming into the focus of scientific interest in recent years.

Objective

This article aims to provide an overview of the clinical symptoms, pathophysiology, diagnostics and potential treatment options of CE in recurrent implantation failure and recurrent miscarriage.

Results

Studies indicate that CE has negative effects on implantation and development in (early) pregnancy via various mechanisms (including an impact on cytokine secretion and alterations in the composition of lymphocyte subpopulations in the endometrium). The immunohistochemical detection of CD138-positive plasma cells in endometrial biopsies has been established as the gold standard for the diagnostics of CE; however, there is still no consensus on the exact diagnostic criteria causing high variations in the reported prevalence of CE in these patient groups of about 10–50%. Successful treatment is achieved with antibiotics, as evidenced both histologically by plasma cell clearance and clinically by higher implantation, pregnancy and live birth rates.

Conclusion

Data on the diagnostics and treatment of CE in patients with recurrent implantation failure and recurrent miscarriage are promising. The determination of exact diagnostic criteria and the treatment of patients with a persistence of CE despite antibiotic treatment are particularly challenging. Further randomized, ideally placebo-controlled, prospective studies with adequate case numbers are needed to provide results in the coming years, so that the value of CE can be further strengthened.

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Authors and Affiliations

  1. Abteilung für Gynäkologische Endokrinologie und Fertilitätsstörungen, Universitätsfrauenklinik Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Deutschland

    Ruben-J. Kuon

  2. The Recurrent Pregnancy Loss Unit, Capital Region Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Kopenhagen, Dänemark

    Kilian Vomstein

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  1. Ruben-J. Kuon
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  2. Kilian Vomstein
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Correspondence to Ruben-J. Kuon.

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Interessenkonflikt

R.-J. Kuon ist Gesellschafter der Reprognostics GbR. K. Vomstein gibt an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Kuon, RJ., Vomstein, K. Bedeutung der chronischen Endometritis bei rezidivierendem Implantationsversagen und wiederholten Fehlgeburten. Gynäkologische Endokrinologie 20, 244–251 (2022). https://doi.org/10.1007/s10304-022-00470-6

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