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EMMA and ALICE tests

Endometrial health is one of the key factors which can impact reproductive health, in fact studies have shown that as high as 20% of fertility problems are potentially caused by issues with the endometrium.

What are EMMA and ALICE tests?

EMMA and ALICE are screening tests that assess bacteria in the uterine cavity.

It is usual for there to be bacteria in the uterine cavity however, studies show that the presence of bacteria that cause inflammation or illness may be associated with embryo implantation failure.

The EMMA test includes a complete screen of endometrial bacteria, including those affecting fertility. It looks at the endometrial microbiome and determines the healthy bacteria levels that may play a role in embryo implantation. Probiotic treatment may be suggested to balance the endometrial flora with the aim of improving chance of pregnancy.

ALICE is a more focused, but limited test, that looks specifically for bacteria that cause chronic, low-grade infection of the womb lining (endometritis). It looks for 8 bacteria that are potentially harmful to an implanting embryo and treatment can include antibiotics.

Why would I have bacteria in my womb?

It is normal to have bacteria throughout the body, including in the vagina and womb. The body contains good bacteria that do us no harm and protect us from harmful bacteria. Occasionally, the number and type of bacteria can change (after illness or antibiotic treatment, for example). Although there may be no signs of infection, changes in the microbiome can change conditions such as the acidity inside the womb, and this can affect fertility. Sometimes very low-grade infections within the womb can cause inflammation that may affect an embryo's ability to implant.

How are the tests done?

We take a small amount of endometrial tissue which is then analysed to provide a complete profile of the bacteria present in the tissue.

Are there any risks?

An endometrial sampling can be associated with a small risk of bleeding and infection. There is also a very small chance of uterine perforation. In some cases, there is a “No-diagnosis” result, which could be due to bacterial DNA levels below the detection limit of the technique, sample degradation or sample contamination during collection or shipment. If this should occur, it will be assessed whether a new biopsy will be required.

Who can benefit from EMMA or ALICE testing?

EMMA may be beneficial for any patient struggling to conceive.

For patients with unexplained infertility, it may allow us to identify a condition that could be negatively impacting fertility.

The EMMA test is recommended for most people as it provides more detail (including all of the screening included in the ALICE test) than the ALICE test, which is only advised for patients trying to conceive naturally but who have suffered from recurrent pregnancy loss.

We recommend EMMA for patients including people who:

  • have had three or more implantation failures following the transfer of good quality embryos or who have had a failed treatment using embryos created with donated gametes or donated embryos
  • have endometriosis. We recommend this as some reports describe alterations in bacteria in patients with endometriosis
  • people who have suffered recurrent miscarriage and who have had a D&C procedure, we recommend this as the microbiome can change after such a procedure

Understanding the effectiveness of EMMA and ALICE

EMMA and ALICE tests are classified as an ‘add-on’ to treatment. The independent regulator of fertility treatment, the Human Fertilisation and Embryology Authority (HFEA), has developed a ‘red-amber-green’ rating system to provide information about treatments that are offered on top of your routine fertility treatment – known as treatment add-ons. They consider that the only way to be confident that a treatment is effective enough to be used routinely is to carry out a randomised controlled trial (RCT). In an RCT, patients are assigned randomly to two groups: a treatment group, given the new treatment and a control group, given either a well-tried treatment or a placebo.

For more information on treatment add-ons, please refer to the HFEA website

You must have all the information you need before you decide on which, if any, 'add-on' diagnostic tests or treatments to use.

What should I do if I want this test?

Before deciding to go ahead with this test, it is important to have a full discussion with your fertility specialist who will consider all aspects of your medical history. Your fertility specialist will discuss the implications, benefits and risks.