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If you're in the middle of IVF and things aren’t going to plan — like perfectly good embryos not implanting — it’s beyond frustrating. You’re following every step, doing all the right things, and still left with more questions than answers.
That’s where EMMA and ALICE testing come in. These tests take a closer look at your uterine lining, checking for hidden infections or an imbalance of bacteria that might be quietly messing with implantation, even when everything else looks fine.
What is EMMA and ALICE testing?
EMMA and ALICE are two advanced diagnostic tests that analyze the endometrial microbiome — a fancy term for the ecosystem of bacteria inside the uterus. They help identify if an imbalance of bacteria or chronic inflammation might be impacting fertility.
EMMA (Endometrial Microbiome Metagenomic Analysis) evaluates the balance of good vs. bad bacteria in the endometrium (the lining of the uterus).
ALICE (Analysis of Infectious Chronic Endometritis) screens for chronic endometritis, a persistent inflammation of the uterine lining caused by infection.
These tests are typically recommended if you've had repeated implantation failure, recurrent miscarriage, or unexplained infertility. They can be done separately or together, often alongside the ERA test (Endometrial Receptivity Analysis), which tests specifically for your personal best timing for embryo transfer.
Why the uterine microbiome matters
It might sound wild, but the bacteria living in the uterus play a major role in fertility. A healthy endometrial microbiome helps support embryo implantation and early pregnancy. When harmful bacteria take over, or if good bacteria are missing, the risk of implantation failure or miscarriage can go up.
In fact, studies have shown that women with a healthy Lactobacillus-dominant microbiome have better outcomes during IVF. On the other hand, when bacterial pathogens are present, they can lead to chronic inflammation, which can quietly prevent pregnancy from sticking.
What does the ALICE test for?
The ALICE test specifically checks for chronic endometritis (CE), a low-grade and often silent infection of the endometrium. It’s not the same as a typical infection that causes symptoms like pain or fever. In fact, most people with CE don’t even know they have it.
ALICE uses advanced molecular techniques to detect the bacteria most commonly responsible for CE, including:
- Escherichia coli
- Enterococcus faecalis
- Streptococcus species
- Staphylococcus species
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“About 1 in 3 patients with recurrent implantation failure have a displaced WOI (window of implantation), meaning their receptive phase occurs earlier or later than expected. Adjusting transfer timing based on ERA can improve synchronization between the embryo and endometrium, thus increasing the chance of successful implantation.”
According to research published in Reproductive Biology and Endocrinology, chronic endometritis is found in up to 42% of women with recurrent implantation failure. The good news? When treated, pregnancy rates can significantly improve.
Treatment typically involves a targeted course of antibiotics based on the bacteria found. The goal is to restore a healthy uterine environment before another embryo transfer.
What bacteria does EMMA test for?
EMMA evaluates the endometrial microbiome with a deep dive into the presence and relative amount of different types of bacteria, especially Lactobacillus species, which are considered the "good" bacteria for reproductive health.
Lactobacillus helps maintain a slightly acidic environment that prevents the growth of harmful bacteria. A lack of Lactobacillus or a dominance of other bacteria like Gardnerella vaginalis, Atopobium vaginae, or Prevotella species can be problematic.
One study found that having less than 90% Lactobacillus in the endometrium was associated with significantly lower implantation and pregnancy rates.
EMMA also includes ALICE testing by default, so you get both microbiome and chronic inflammation insights in one go.
When are EMMA and ALICE tests recommended?
EMMA and ALICE tests are often recommended when there’s no clear reason why IVF isn’t working. If you’ve had two or more failed embryo transfers, experienced recurrent miscarriages, or are dealing with unexplained infertility, your doctor might suggest taking a closer look at your uterine health. Even if your embryos look great and your hormone levels are all in range, there could still be something going on inside the endometrium that’s stopping implantation from happening.
These tests are usually done during the luteal phase of your cycle — around day 19 to 21 — when your uterine lining is most receptive. The process itself is quick and relatively simple, involving a small biopsy of the endometrial tissue. While it might feel a little uncomfortable, it’s over in minutes and could give you the kind of answers that make all the difference moving forward.
What happens after the results?
Once your results come back — which usually takes about two weeks — your fertility specialist will go through them with you and help map out the next steps. Depending on what the tests show, your treatment plan might include a short course of antibiotics to clear out any lingering infection, or probiotics to help rebalance the good bacteria in your uterus. If you’ve also had an ERA test, your doctor might recommend tweaking the timing of your embryo transfer to better match your unique window of implantation.
The goal is to create the most supportive environment possible for an embryo to implant and grow. These kinds of personalized treatment plans can feel like a breath of fresh air when you've been stuck in the “everything looks fine” cycle. They offer real, actionable steps — based on what’s actually going on in your body — and can help make your next transfer feel more informed, more hopeful, and just a little less out of your hands.
This approach is known as personalized embryo transfer (pET) and has been linked with improved pregnancy outcomes for people with previous IVF failure.
Are there any risks or downsides?
EMMA and ALICE are low-risk tests, but like any medical procedure, there are a few things to consider:
- Mild cramping or spotting after the biopsy
- Out-of-pocket costs (not always covered by insurance)
- Timing the test correctly with your cycle can be tricky
Still, many people find the answers they get are worth it, especially when they’ve been stuck in the frustrating cycle of "everything looks normal" with no explanation for why things aren’t working.
Mental health and fertility: a holistic picture
When dealing with infertility, it’s not just about the physical stuff. The emotional toll is real. Testing like EMMA and ALICE can offer clarity, which helps reduce some of the mental strain. Having a concrete reason and a plan forward can make a world of difference.
That said, these tests aren’t a cure-all. They’re one part of a bigger picture. A healthy lifestyle, emotional support, and compassionate fertility care are all essential too.
What EMMA and ALICE could mean for your TTC journey
If you're navigating IVF or trying to conceive without success, EMMA and ALICE testing can offer valuable insights into your uterine health. They help pinpoint hidden issues that might otherwise go unnoticed — and when you’re doing everything right but not getting results, those answers matter. For so many, it’s the first time they’ve felt like the focus isn’t just on the embryo, but on the environment it’s being placed into — something that’s just as important, and too often overlooked.
It’s okay to feel frustrated, tired, or overwhelmed. But it’s also okay to feel hopeful again. With tools like EMMA and ALICE, you're gathering real, science-backed information that can help move things forward. No more “everything looks normal” when you know deep down something’s being missed. This is about advocating for your body, getting clarity, and finding the right support on your path to parenthood — whatever that may look like for you. You deserve care that sees the full picture.
Tassia O'Callaghan is an experienced content writer and strategist, having written about a vast range of topics from chemical regulations to parenting, for brands like Peanut App Ltd, Scary Mommy, Tally Workspace, and Fertility Mapper. She's an advocate for realistic sustainable living, supporting small businesses (author of A-Z of Marketing for Small Businesses), and equity across all walks of life. Follow her on LinkedIn or TikTok, or see more of her work on Authory or her website.