Advanced Endometrial Receptivity Tests: Complete Guide to ERA, EMMA & ALICE

UPDATED ON 25 JUNE 2025

If you’ve faced the emotional weight of a failed IVF cycle or a heartbreaking miscarriage, you’ve likely heard about advanced tests like ERA, EMMA, and ALICE. These sound highly scientific—and they are—but as a reproductive immunologist in India, I believe it’s my responsibility to help you understand what these tests really mean for you.

In this article, I’ll walk you through what each test does, when it’s actually helpful, and why, in many Indian cases, they may not be necessary. My goal is simple: to help you make informed, confident decisions—not overwhelmed or anxious ones

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TREATMENT

IVF

CONDITION

Repeated Miscarriages

Failed IVF Cycles

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What Are ERA, EMMA, and ALICE Tests?

These are three endometrial tests usually done together from a single biopsy, which is taken usually in the mid-luteal phase.

📌ERA—Endometrial Receptivity Analysis

• Checks when your uterus is most receptive to embryo implantation
• Assess genetic markers to determine your personal Window of Implantation (WOI)

📌 EMMA – Endometrial Microbiome Metagenomic Analysis

• Evaluates the bacterial environment in your uterus
• Looks for healthy bacteria like Lactobacillus and harmful ones that could affect implantation

📌 ALICE—Analysis of Infectious Chronic Endometritis

• Identifies low-grade infections or chronic inflammation in the endometrium

These tests are done during the mid-luteal phase (around days 20–24 of your cycle) to match your natural window of implantation.

What Do These Tests Cost in India?

Let me be upfront—they’re expensive.

• In India, the ERA, EMMA, and ALICE tests used for fertility evaluation typically cost around ₹80,000.
• The report is usually going to be available within 3 to 4 weeks of taking the primary biopsy. 

This is a significant investment, especially since most fertility treatments in India are out-of-pocket expenses.

Do You Really Need These Tests After One Failed IVF or Miscarriage?

Short answer: No, not usually.

These are not routine tests I recommend for every patient. Let me explain why:

• These are proprietary tests that don’t offer much benefit for most people in India, so we use them very selectively—mainly for patients referred to us after failed IVF or previous abortion

• The clinical evidence for their benefit in broader populations—like most Indian patients—is still limited.

We see many couples who’ve had one failed IVF or miscarriage and are recommended these tests unnecessarily. The real issue? Sometimes it’s not the endometrium—it’s the embryo’s genetic quality. 

Once upon a time, approximately 3 to 4 years back, ERA was very popular. But from our experience, we’ve found it doesn’t offer much value to patients.

The test works by checking gene activity in a particular cycle, and its results are only valid for a month or two. In India, patients often go through unnecessary tests during in vitro fertilization (IVF), sometimes just to feel reassured—even if the tests don’t really help.

Focus First on Forming Chromosomally Normal (Euploid) Embryos

One of the most important things to focus on during IVF is forming euploid embryos—that means embryos with the correct number of chromosomes. These healthy embryos are more likely to communicate well with the uterus lining (endometrium), which helps them implant successfully and grow into a pregnancy.

Tests like the Window of Implantation (WOI) are only useful when we already have genetically normal (euploid) embryos and are trying to find the best time for them to implant. 

If a couple is not forming euploid embryos, it’s more important first to check and improve egg quality, sperm health, and how the embryos are developing—before thinking about doing this test.

This is why I often advise couples to first look into factors like

• Egg and sperm quality
• Embryo grading

Embryo biopsy for PGT-A, if indicated

Why We Rarely Recommend EMMA in India?

Let’s talk about the endometrial microbiome.

In India, testing for healthy uterine bacteria through EMMA is especially challenging. That’s because the natural number of beneficial bacteria—like Lactobacillus—in the uterus is already very low. 

Even a tiny contamination during the biopsy (which can easily happen from the cervix or vaginal tract) may lead to inaccurate or misleading results. This makes the reliability of EMMA testing in Indian clinical settings questionable, especially when considering the high cost.

So What’s the Alternative?

A simple oral probiotic.

• Widely available
• Cost-effective
• Can help replenish healthy bacteria naturally
• Doesn’t require invasive or expensive testing

In fact, I often recommend oral probiotics to couples who might benefit, without the need for EMMA.

What About ALICE for Chronic Endometritis?

ALICE can detect chronic inflammation, but again, it’s not always necessary.

In our practice, we prefer:

• MUM1 biopsy: A more affordable, targeted test to detect plasma cells, which signal inflammation

It’s:

• Cost-effective
• Reliable
• More suited for Indian settings

Important Caveats About ERA

ERA was once seen as a game-changer, but:

• It relies on gene expression for that particular cycle only
• Its accuracy is valid for just 1–2 months
• It doesn’t benefit all patients equally

In our Shree IVF and Endometriosis Clinic, Mumbai, we’ve seen limited value from ERA over the years. We prefer not to recommend it unless there’s a clear indication, like repeated IVF failures with euploid embryos.

My Honest Recommendation

I understand the emotional toll of failed cycles. But throwing every expensive test at the problem isn’t the solution.

As your reproductive immunologist, I recommend:

• Prioritizing genetically normal embryo formation
• Assessing egg, sperm, and embryo quality
• Using oral probiotics if microbiome health is a concern

Considering immune tests like MUM1, BCL-6, or uNK where indicated

Final Thoughts: Should You Do ERA + EMMA + ALICE?

Only if:

• You’ve had multiple IVF failures with good-quality embryos
• Your doctor suspects chronic endometritis that hasn’t responded to treatment
• You’re fully aware of the costs, limitations, and benefits

Otherwise, these tests are best reserved for very specific, well-evaluated cases.

Always discuss your options thoroughly with your fertility expert before moving forward.

If you’re feeling confused about testing, implantation, or why things haven’t worked out so far—let’s talk. I’m Dr. Jay Mehta, a reproductive immunology and IVF failure specialist. With over 1000+ complex fertility cases personally evaluated, I’m here to help you understand what’s going on and what can be done next. Consultations available in Mumbai or online.

AUTHOR

TREATMENT

IVF

CONDITION

Repeated Miscarriages

Failed IVF Cycles

CALL US 24/7 FOR ANY HELP

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