Beyond the Silent Endometrium: Dysbiosis, Immune Subversion and Antimicrobial Resistance in Chronic Endometritis: A Narrative Review.

Chronic endometritis (CE) represents an insidious and frequently underdiagnosed inflammatory condition of the endometrial stroma, increasingly recognized as a principal contributor to unexplained infertility, recurrent implantation failure and recurrent pregnancy loss. Historically relegated to a histological curiosity, CE has been reframed as a biologically complex disorder characterized by the convergence of endometrial microbial dysbiosis, immunological subversion, and, increasingly, antimicrobial resistance (AMR). This narrative review synthesizes contemporary evidence examining the mechanistic interplay between aberrant endometrial microbiota composition, disrupted innate and adaptive immune responses, and the emergence of antibiotic-resistant endometrial pathogens, collectively undermining endometrial receptivity and embryo implantation. We critically appraise the diagnostic limitations inherent to current histological and microbiological standards, and examine the translational implications of next-generation sequencing for the characterization of the endometrial microbiome. Furthermore, we interrogate the therapeutic paradox posed by AMR in clinical CE management, and delineate future research trajectories encompassing microbiome-targeted therapeutics, immunomodulatory strategies, and the ethical dimensions of emerging diagnostic and treatment frameworks. A convergent pathophysiological model is proposed in which microbial dysbiosis, immune dysregulation, and AMR form a self-reinforcing axis of reproductive failure, demanding integrated diagnostic and therapeutic paradigms.