What uterine factors are U.S. doctors focusing on today?

legend family
Dec 18, 2025
2 min read

Chronic Endometritis (CE)

Chronic endometritis has become an increasingly discussed topic in recent years.

Most patients have no obvious symptoms
Ultrasound and routine exams are often normal
Yet it can significantly interfere with embryo implantation

At its core, CE represents a state of persistent low‑grade inflammation within the endometrium—an environment that is not ideal for embryo attachment and growth.

When endometrial thickness looks adequate, but function may not be

Patients often ask:

“My lining is 8–9 mm—doesn’t that mean it’s good?”

From a U.S. physician’s perspective:

Thickness does not equal receptivity
Appearance does not reflect the microscopic environment

This is why ultrasound assessment alone is no longer sufficient in certain cases.

What are EMMA and ALICE tests, and what do they evaluate?

EMMA and ALICE are functional endometrial tests that are increasingly used in U.S. fertility clinics.

These tests are typically performed:

During a natural or medicated cycle
In a mock transfer cycle
At a specific, time‑sensitive window
Using an endometrial biopsy

EMMA: Endometrial Microbiome Analysis

The EMMA test evaluates:

The balance between beneficial and non‑beneficial bacteria in the endometrium
Whether Lactobacillus species are dominant

Research has shown that a Lactobacillus‑dominant uterine environment is associated with higher implantation potential.

ALICE: Pathogen Detection Related to Chronic Endometritis

The ALICE test focuses on:

Identifying specific pathogens associated with chronic endometritis
Detecting infection even in the absence of symptoms

If ALICE results are positive, physicians typically:

Prescribe targeted antibiotic therapy
Reassess before proceeding with embryo transfer

Why are EMMA and ALICE clinically meaningful?

These tests are not performed to increase testing, but to reduce repeated failure.

From a physician’s standpoint:

One additional evaluation
May significantly improve the odds of a successful transfer

What about ERA testing? Why is it discussed less frequently now?

ERA (Endometrial Receptivity Analysis) has not disappeared, but its use in the U.S. has become more selective.

Reasons include:

Limited evidence of improved overall live birth rates
Not appropriate for every patient
Primarily considered after repeated failures when other factors have been ruled out

The current clinical approach often follows this sequence:

Address inflammation and microbiome balance first, then consider whether ERA is necessary.

Final thoughts: This is refinement, not over‑testing.

When patients hear that additional testing is recommended, a common reaction is:

“Is this just more procedures?”

From the U.S. physician’s perspective, this shift reflects a move:

Away from probability‑based medicine
Toward truly individualized care

Embryos are critically important. But the uterus is the environment where the embryo must thrive for nine months.

If you have high‑quality embryos yet continue to face unsuccessful transfers, it may be time to gently shift focus—from the embryo alone—to the uterine environment as well.

If you have questions about EMMA, ALICE, the endometrial biopsy process, or whether these tests may be appropriate for you, feel free to reach out for further discussion.