EMMA / ALICE (Endometrial Microbiome Testing)

By RRM Academy Reviewed by Dr. Naomi Whittaker, MD, Board-Certified OBGYN, MIGS, NFPMC, FCI Updated May 14, 2026

EMMA and ALICE are molecular diagnostic tests that analyze the endometrial microbiome from a biopsy sample. EMMA (Endometrial Microbiome Metagenomic Analysis) measures the composition of bacteria present in the endometrium, including the proportion of Lactobacillus species, which research associates with better implantation outcomes, and the presence of dysbiotic organisms. ALICE (Analysis of Infectious Chronic Endometritis) identifies specific pathogenic bacteria associated with chronic endometritis, a condition linked to recurrent implantation failure and recurrent pregnancy loss.¹

The two tests are typically ordered together and can be run from a single endometrial biopsy sample, often alongside ERA as a combined panel. The theoretical basis rests on evidence that the endometrial microbiome is not sterile and that its composition may influence the likelihood of successful implantation.¹²

The published evidence in this area is observational and preliminary. The 2016 Moreno study established that a non-Lactobacillus-dominant endometrial microbiota correlated with lower implantation and pregnancy rates in IVF patients. This finding generated interest in microbiome-targeted treatment, including probiotic and antibiotic protocols guided by EMMA and ALICE results. Controlled trial data supporting this approach remain limited. No published RCT has established the clinical utility of routine endometrial microbiome testing.¹

EMMA and ALICE are used in the context of IVF workup for recurrent implantation failure. They do not address the structural, hormonal, or immunological causes of implantation failure that constitute the core of root-cause evaluation. For patients with suspected chronic endometritis, the more established diagnostic standard is endometrial biopsy with CD138 immunohistochemistry, which identifies plasma cell infiltration as the histologic marker of the condition.

This content is for educational purposes only and does not constitute medical advice. Consult an RRM clinician or healthcare provider for guidance specific to your situation.