EMMA / ALICE (Endometrial Microbiome Testing)

EMMA and ALICE are lab tests that check the bacteria in the endometrium, the lining of the uterus. Both tests use a small tissue sample from the lining (endometrial biopsy). EMMA (Endometrial Microbiome Metagenomic Analysis) measures the mix of bacteria in the endometrium. It measures the share of Lactobacillus in that mix. Research links this helpful bacterium to better implantation. EMMA also looks for bacteria that upset the balance. ALICE (Analysis of Infectious Chronic Endometritis) looks for specific harmful bacteria. These bacteria are linked to chronic endometritis, a long-term inflammation of the lining. That condition is linked to repeated failed implantation and to recurrent pregnancy loss.¹

The two tests are usually ordered together. One biopsy sample can run both tests. They are often paired with ERA as a single panel. The idea behind them is that the endometrium is not sterile. The bacteria that live there may affect whether an embryo implants.¹²

The research here is early and based on observation. A small 2016 study by Moreno and colleagues looked at 35 women going through IVF. Women whose endometrium was not dominated by Lactobacillus had lower rates of implantation, pregnancy, and live birth.¹³ The study showed an association. It did not prove that the bacteria caused the failures. The finding sparked interest in probiotic and antibiotic treatment guided by EMMA and ALICE results. Data from controlled trials of this approach remain limited. No published randomized trial has shown that routine testing of these bacteria helps couples.

EMMA and ALICE are used mainly in IVF workups after embryos fail to implant. They do not assess the structural, hormonal, or immune causes of failed implantation. Those causes are the core of a root-cause evaluation. For suspected chronic endometritis, the more established test is an endometrial biopsy stained for CD138. This stain finds plasma cells, the tissue marker of the condition.