Unified diagnostic criteria for chronic endometritis at fluid hysteroscopy: proposal and reliability evaluation through an international randomized-controlled observer study

Abstract

Objective: To develop a consensus on the diagnostic criteria for chronic endometritis (CE) at hysteroscopy (HSC), and to evaluate these proposed criteria in a randomized-controlled observer study. Design: Systematic review of studies evaluating the diagnostic accuracy of HSC in CE diagnosis; Delphi consensus on hysteroscopic diagnostic criteria for CE; randomized-controlled observer study to evaluate the reproducibility of the proposed diagnostic criteria. Setting: Not applicable. Participant(s): Experts from different countries were involved in the systematic review and contributed to the Delphi consensus. Physicians from different countries were involved in the observer study. Intervention(s): After reaching consensus on the diagnostic criteria, the Delphi poll created a questionnaire including 100 hysteroscopic pictures (50 from women with CE [domain 1] and 50 from women without CE [domain 2]), with a single question per picture (Answer_A: suggestive of CE; answer B: not suggestive of CE). A total of 200 physicians were invited to take part in the observer study. Before completing the questionnaire, physicians were randomized to receive a description of the diagnostic criteria (group A) or no such information (group B). Main Outcome Measure(s): The primary outcome was to compare the questionnaire scores for the two groups of observers. The secondary outcome was to assess the interobserver agreement in the diagnosis of CE in each group. Result(s): A total of 126 physicians completed the questionnaire (62 in group A and 64 in group B). Observers in group A obtained higher total scores compared with those in group B (P< .001). Specifically, group A showed higher mean score in domain 1 (P< .001), but not in domain 2 (P¼ .975). A substantial agreement was found among observers in group A (intraclass correlation coefficient [ICC] 0.78), whereas a fair agreement was found among observers in group B (ICC 0.40). Conclusion(s):This randomized-controlled observer study found a positive impact of our criteria on physicians' ability to recognize CE. (Fertil Steril Ò 2019;112:162-73. Ó2019 by American Society for Reproductive Medicine.) El resumen está disponible en Español al final del artículo.

In women with chronic or subclinical endometritis is hysteroscopy suitable for setting the diagnosis? A systematic review

“…In the majority of hysteroscopically suspected cases of CE the confirmation was made through histology (13 out of 15), in which CD-138 immunoreactivity, was used as a marker for CE in only five out of 15 histologic confirmations ( Table 2). In one study of Cicinelli et al, 12 details of confirmation are not available. In some studies where histologic confirmations were used, immunohistochemistry (IHC) staining was applied and the pathologists set the diagnosis of CE in the presence of five or more plasma cells in endometrium stroma in high power fields, 10,14,20 while in others traditional hematoxylin and eosin (H&E) staining was performed.…”

“…Sixteen studies were selected in full text as potentially suitable for inclusion. [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] One study was subsequently excluded:…”

“…One study had an hysteroscopic indication of AUB, 22 another of endometrial hyperplasia, 18 as well as of endometrial polyp 10 and the remaining four had no specific indication rather than common gynecological conditions including the ones mentioned previously. 7,12,15,16 The authors compared their hysteroscopically suspected cases with methods of histology, immunochemistry, molecular biology and microbiology. In the majority of hysteroscopically suspected cases of CE the confirmation was made through histology (13 out of 15), in which CD-138 immunoreactivity, was used as a marker for CE in only five out of 15 histologic confirmations ( Table 2).…”

“…6 A number of studies found histology with CD-138 to be superior of conventional histology, meaning plain identification of plasma cells in an endometrial biopsy. 7,13 In an interesting randomized-controlled observer study, Cicinelli et al 12 proposed the 'Delphi' diagnostic criteria for setting the diagnosis of CE:…”

“…According to this study, the proposed criteria increase the ability of the hysteroscopists to detect and finally diagnose cases of CE, without increasing false-positive diagnosis. 12…”