Analysis of endometrial histopathological classifications and associated factors in infertile women with heterogeneous endometrial echogenicity

Infertility is a key reproductive health challenge, with endometrial lesions as a major cause. Heterogeneous endometrial echo is an initial screening tool, and hysteroscopy plus pathology is the diagnostic gold standard. This study explored pathological subtypes, risk factors of heterogeneous echo in infertile women, and predictive models’ performance. This study analyzes the histopathological classifications and associated influencing factors of endometrial tissue in infertile women with heterogeneous endometrial echogenicity identified on ultrasound. It also seeks to explore the clinical value of such echogenic patterns in diagnosing endometrial lesions, thereby providing evidence-based support for the clinical diagnosis and management of these patients. This was a cross-sectional study that enrolled infertile patients undergoing hysteroscopy due to heterogeneous endometrial echogenicity. We analyzed the histopathological classifications of the endometrium and its associated influencing factors. A total of 312 infertile women with heterogeneous endometrial echo were retrospectively analyzed. Clinical data, hysteroscopic findings, and pathology results were collected. Group comparisons, Spearman correlation, logistic regression, receiver operating characteristic curves/confusion matrices, neural network, and restricted cubic spline were used. A total of 227 (72.8%) had endometrial lesions (chronic endometritis: 175, 56.09%; polyps: 85, 27.24%; hyperplasia: 106; fibroids: 2); 85 (27.24%) were negative. Body mass index, infertility duration, and endometrial thickness correlated positively with lesions ( P < .05); infertility type correlated negatively ( r =−0.158, P = .005). Body mass index (BMI) and endometrial thickness were independent risk factors. The exploratory neural network analysis identified endometrial thickness as the most important predictor (normalized importance score = 0.301), followed by BMI (0.245) and age (0.229). The internally validated multivariable logistic regression model achieved the area under the receiver operating characteristic curve of 0.701 (0.637–0.760) and the area under the precision-recall curve of 0.859 (0.808–0.902). At the Youden-optimal threshold of 0.733, sensitivity and specificity were 0.652 and 0.670, respectively. Restricted cubic spline analysis suggested a nonlinear association, with the estimated adjusted odds ratios increasing modestly above the 10-mm reference value. Chronic endometritis and polyps are common in these women. BMI, endometrial thickness, and infertility duration are key risk factors. BMI and endometrial thickness were independently associated with endometrial lesions, while the internally validated prediction model showed modest discrimination, emphasizing ultrasound monitoring and weight management for diagnosis/treatment.