Bengaluru: Milann - Fertility and Birthing Hospital, Bengaluru successfully managed a challenging case of chronic endometritis, a silent inflammatory condition of the uterus that can affect embryo implantation and pregnancy outcomes, helping a 39-year-old woman achieve an ongoing IVF pregnancy under the expert supervision of Dr. Shilpa Ellur, Senior Consultant, Reproductive Medicine & High-Risk Obstetrics. The case highlights the importance of routine fertility evaluations and identifying hidden uterine factors that may impact pregnancy, even when a genetically normal embryo is available.

Chronic endometritis (CE) is a persistent, low-grade inflammation of the endometrium, which is the inner lining of the uterus where an embryo attaches and develops. Unlike acute infections that usually present with fever, severe pelvic pain, and obvious symptoms, chronic endometritis often remains silent or presents with mild symptoms such as abnormal vaginal discharge, mild pelvic discomfort, or irregular bleeding. It is increasingly recognized as an important factor associated with unexplained infertility, recurrent implantation failure to the uterine lining, and recurrent pregnancy loss.

Mrs. K, a 39-year-old woman, along with her 40-year-old husband, visited Milann - Fertility and Birthing Hospital, Bengaluru in June 2024 with concerns regarding difficulty conceiving their second child for the past five years. The couple had been married for 12 years and had one previous live birth, a 10-year-old daughter. Mrs. K had regular menstrual cycles with normal flow and no pain. She was a known case of hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormones, and was taking Thyronorm 12.5 mcg. Her husband, an IT professional, was also diagnosed with hypothyroidism and hypertension, both of which were under control with medication.

Before approaching Milann, the couple had undergone two unsuccessful cycles of ovulation induction with intrauterine insemination (IUI).

During evaluation, Mrs. K had a BMI of 34.6 kg/m², haemoglobin of 13 g/dL, TSH of 3.5 mIU/mL, HbA1c of 5.3%, Anti-Müllerian Hormone (AMH) of 1.27 ng/mL, and non-reactive serology. Hysterosalpingography (HSG), an imaging test used to check the condition of fallopian tubes, and here both tubes were patent (open).

Pelvic ultrasound revealed an anteverted, anteflexed bulky uterus with features suggestive of adenomyosis. Adenomyosis is a condition where tissue similar to the inner lining of the uterus grows into the muscular wall of the uterus and may interfere with embryo implantation. The endometrial thickness was 7.6 mm. The ovarian reserve was satisfactory, with 7–8 antral follicles in the right ovary and 8 follicles in the left ovary. Her husband’s semen analysis showed teratozoospermia, a condition where sperm have abnormal shapes that may affect their ability to fertilize an egg. Considering the couple’s age, previous failed IUI attempts, adenomyosis, and male factor infertility, IVF/ICSI was planned. 

The patient underwent an antagonist stimulation protocol, where fertility medications are used to stimulate multiple eggs while preventing premature ovulation. She received Inj. Menopur 375 IU, and oocyte retrieval was performed 35 hours after dual trigger administration. A total of 10 eggs were retrieved, of which 8 were mature eggs. All eight mature eggs fertilized successfully, resulting in eight developing embryos and five blastocysts, which are advanced-stage embryos suitable for transfer.

The blastocysts were graded as three 3AB, one 3BB, and one 3BC based on their appearance and developmental quality. Considering the presence of adenomyosis, a Mirena intrauterine system was inserted during egg retrieval to help optimize the uterine environment before embryo transfer.

One 3AB blastocyst underwent PGT-A (Preimplantation Genetic Testing for Aneuploidy), a genetic screening procedure performed on embryos before transfer to identify chromosome abnormalities. The test showed one euploid embryo, meaning an embryo with the correct number of chromosomes and a higher potential for successful implantation. The remaining embryos were found to have chromosomal abnormalities.

The couple returned in May 2025 for Mirena removal and preparation for frozen embryo transfer. However, multiple hormone replacement therapy (HRT) cycles, where medications are used to prepare the uterine lining for embryo transfer, had to be cancelled due to persistent infection symptoms and unhealthy vaginal discharge. This prompted further investigation into the condition of the uterine lining.

A hysteroscopy, a minimally invasive procedure using a thin camera to examine the inside of the uterus, was performed along with an endometrial biopsy. The biopsy samples were evaluated through histopathological examination, culture and sensitivity testing, and immunohistochemistry (IHC), a specialized laboratory technique that uses specific markers to identify certain cells.

The immunohistochemistry results revealed 20 MUM-1 positive plasma cells, confirming the diagnosis of chronic endometritis. Plasma cells are immune cells that normally help fight infections, but their presence in increased numbers within the uterine lining indicates persistent inflammation.

The patient was treated with targeted antibiotic therapy, along with vaginal probiotics to help restore healthy vaginal bacteria.

Following successful treatment of chronic endometritis, a modified natural cycle preparation was performed. The single euploid 3AB embryo was transferred, resulting in a positive pregnancy with a beta-hCG level of 590 IU/mL. The patient is currently progressing well with an ongoing pregnancy of seven weeks.

Dr. Shilpa Ellur, Senior Consultant, Reproductive Medicine & High-Risk Obstetrics, Milann - Fertility and Birthing Hospital, Bengaluru, said, “Chronic endometritis is a silent but significant cause of infertility and recurrent implantation failure, and this case reinforces the importance of looking beyond routine evaluations when pregnancy does not occur. With advanced diagnostics such as hysteroscopy and immunohistochemistry, followed by targeted treatment, we were able to identify the hidden barrier to implantation and help the patient achieve a successful IVF pregnancy. This outcome is a powerful reminder that personalized care and timely intervention can transform even the most challenging fertility journeys.”

The patient shared, “After years of waiting and multiple unsuccessful attempts, achieving this pregnancy feels like a dream come true. The support, guidance, and personalized care we received at Milann gave us renewed hope. We are deeply grateful to Dr. Shilpa Ellur and the entire team for helping us overcome this challenging journey.”

This case highlights the importance of considering chronic endometritis as a hidden factor in patients facing implantation challenges. While chronic endometritis is a recognized condition in reproductive medicine, its silent nature often makes diagnosis difficult. Through advanced diagnostic evaluation, timely treatment, and personalized fertility care, Milann successfully identified and addressed this hidden barrier, helping the couple move closer to achieving their dream of parenthood.