What is EMMA & ALICE Testing?
EMMA (Endometrial Microbiome Metagenomic Analysis) uses genetic testing to assess the bacteria that is living within your uterine cavity. Rather than traditional microbiology testing it analyses the DNA of any bacteria to identify it more accurately. This allows the clinician to determine if the uterine microbial environment is optimal for embryo implantation. EMMA provides a complete view of the endometrial bacteria, including pathogens that may affect implantation whilst ALICE (Analysis of Chronic Infective Endometritis) is a more focused test that looks specifically for bacteria that cause chronic, low grade infection of the womb lining (endometritis).
The EMMA test is a more complete test and includes all the tests performed for ALICE and we would recommend this as an option.
Would my swab test not have picked up this bacteria ?
Microbial culture is the current method for identification of bacteria and infection. However, it has been demonstrated that, depending on location, between 20% and 60% of bacteria cannot be detected especially some of the bacteria implicated in chronic infection and changes to the environment of the womb. EMMA and ALICE use testing of bacterial DNA to identify bacteria within the uterine cavity with greater certainty (Moreno et al 2018).
Why would I have bacteria in my womb?
It is normal to have bacteria throughout the body including the vagina and womb. Every part of our body is usually covered in bacteria that does us no harm and acts as a protection from harmful bacteria , occasionally these bacterial levels can change and although they may not cause signs of infection they can be associated with changes in the conditions inside the womb such as the pH (amount of acid) which can affect fertility. Sometimes some very low grade infections within the cavity of the womb can affect the cells lining the womb by causing inflammation that may affect the embryos ability to implant.
What is chronic infective endometritis and how does it affect fertility?
Chronic endometritis (CE) is the persistent inflammation of the endometrium, mainly caused by bacterial infection. It affects approximately 30% of infertile women, but prevalence in patients with Repeated Implantation Failure (RIF) and Recurrent Pregnancy Loss (RPL) can reach 60%. This disease is asymptomatic and is not detectable by ultrasound during standard gynaecological checks. For this reason, it is often overlooked and, therefore, not treated. Diagnosis of CE is traditionally based on histology, hysteroscopy and/or microbial culture. However, these three methods provide inconclusive or misleading results in 80% of cases.
When is EMMA/ALICE recommended?
We would recommend EMMA for patients who have had repeated failures (three or more) of implantation of good quality embryos or who have had a failed treatment with donor embryos (Moreno et al 2016). There is also evidence that when fluid is seen using ultrasound in the uterine cavity there is a much greater incidence of chronic endometritis/ altered microbiome. This test can be done at the same time as an endometrial receptor array test and so we would advise this as an extra to that test for cost effectiveness. However, EMMA may be beneficial for any patient wishing / struggling to conceive, by assessing the microbiological environment that the embryo will encounter at implantation. For patients with unexplained infertility it may allow detection of a treatable condition that may prevent the need for fertility treatment and may prevent treatment where chronic infection may reduce success rates if untreated.
How is the endometrial biopsy collected?
Endometrial biopsies are collected by aspirating cells and tissue that line the uterine cavity using a thin tube (pipelle) passed through the cervix. This is a well-established test that is used routinely in gynaecological practice
When should this test be done?
If you are undergoing an endometrial biopsy for the endometrial receptor array (ERA) test the EMMA test can be performed at the same time using a single endometrial biopsy according to the ERA protocol followed for sample collection. If EMMA or ALICE is requested alone, the endometrial biopsy should be obtained either following the ERA protocol, or between days 15 and 25 in a natural cycle.
How long will it take to get the results?
It will take up to 15 days to get the results.
Do any drugs affect or interfere with the EMMA analysis?
Yes – specifically, antibiotics. You should not have been administered antibiotics during the 3 months prior to sample collection. If you have taken any antibiotic during this timeframe, the name of the medication, its dosage, mode of administration and duration must be recorded in the Test Requisition Form. This includes prophylactic antibiotics for egg retrieval. Other drugs, such as those altering the patient’s microbiota or immunological condition such as steroids , could also affect results, so you should discuss with your clinician to ensure that the optimum time for the test can be determined and the information recorded on your request form.
Does it matter about the thickness of the lining of my womb?
No. The EMMA can be performed if the lining of the womb is thin (<6mm) and when a characteristic three line (trilaminar) endometrium is not present.
What information is provided by the EMMA report?
The EMMA report will provide information about the overall microbial health of the uterine cavity, including:
- The percentage of Lactobacillus.
- The percentages of the ten most abundant bacteria detected in the endometrial sample.
- Whether the endometrial microbiota is normal (high percentage of Lactobacillus), or abnormal (low percentage of Lactobacilli and/or presence of bacterial pathogens).
- Suggested probiotic/antibiotic therapy. Recommendations for antimicrobial therapy will be always guided by an expert clinical microbiologist, who will counsel the patient or the doctor on an individual basis.
If the result is abnormal what happens next?
You will be seen by your clinician to discuss the results and personalise any treatment for you.
Based on EMMA results, a list of recommended antibiotics and/or probiotics will be provided at the end of the report and these can be prescribed by your clinician. Depending upon the report a second biopsy may be requested following treatment with the pro/antibiotics. We anticipate that up to 40% of patients will require a second sample.
If a second sample is required, will it be collected at the same time in my cycle? Is a second sample included in the price?
If only the EMMA test needs to be repeated, the sample can be collected between 15-25 days of the natural cycle, or during the secretory phase in a stimulated cycle. However, we recommend that samples are collected in similar conditions to the first sample. For patients with a previous ‘abnormal’ report for EMMA, a second sample will be analysed free of charge following recommended treatment and confirmation of normal flora restoration.
If I have had an ERA test previously can this test be done on my old sample?
We recommend performing the EMMA test with a new sample, because the microbiota varies over time. However, there may be some special case (in which the piece of tissue is still stored at Igenomix), which can be analysed. There is, however, a risk of contamination if a previous sample is used, due to previous manipulation.
Is there any scientific evidence supporting this test?
There is a paper published by Igenomix in the American Journal of Obstetrics and Gynecology (Moreno et al, 2016), showing the impact of endometrial microbiota on ART success in a pilot study with 35 RIF patients. This paper was published as a Report of Major Impact.
Does anything affect the EMMA result?
There is evidence from sime studies that demonstrate a higher prevalence of microbiota alterations in patients with endometriosis, although further research is needed. This relationship is currently under investigation.We recommend performing the EMMA test in these patients, and request that clinicians record endometriosis in the TRF.
There is also evidence that following a complicated prolonged miscarriage with a D&C the results could change so EMMA is recommended to be repeated in the cycles before embryo transfer.
References
- Moreno I, Cicinelli E, Garcia-Grau I, Gonzalez-Monfort M, Bau D, Vilella F, De Ziegler D, Resta L, Valbuena D, Simon C. The diagnosis of chronic endometritis in infertile asymptomatic women: a comparative study of histology, microbial cultures, hysteroscopy, and molecular microbiology. Am J Obstet Gynecol 2018; doi: 10.1016/j.ajog.2018.02.012.
- Moreno I, Codoñer FM, Vilella F, Valbuena D, Martinez-Blanch JF, Jimenez-Almazán J, Alonso R, Alamá P, Remohi J, Pellicer A, Ramon D, Simon C. Evidence that the endometrial microbiota has an effect on implantation success or failure. Am J Obstet Gynecol 2016; 215:684-703
