Endometrial Health Assessments

At CRGH, we offer a comprehensive assessment of the endometrium. The endometrium is the internal lining of the womb (uterus), where the embryo implants and grows during pregnancy. Recent studies indicate that the endometrium is a key factor for reproductive success.

We offer various tests to assess the health of the endometrium.

The CRGH Quartet includes:

 

  1. ERA (Endometrial Receptivity Assay)
  2. EMMA (Endometria Microbiome Metagenomic Analysis)
  3. ALICE (Analysis of Infectious Chronic Endometritis)
  4. NKT (Natural Killer Test) 

 

The CRGH Quartet will enable us to have a better understanding of your endometrial status in order to improve your chance of pregnancy. All four tests use only one endometrial sample. These tests can also be requested separately for example to have the ERA test or the EMMA test.

 

Whilst there is inconclusive evidence regarding the aforementioned additional investigations and are not obligatory, the clinic will only offer it when your consultant deems it appropriate for the treatment1-9.

 

 

ERA

What is the test?

The ERA test determines the window of implantation that is the precise time when the endometrium is receptive. The window of implantation is normally between day 19 and 21 of the cycle. However, in some women the window of implantation is not the same1-5. In approximately a third of women with recurrent implantation failure this theoretical window is either pre-receptive (before day 19) or post receptive (after day 21)1-5.

 

What are the indications?

The ERA test is indicated in women who have experienced implantation failure with good quality or euploid embryos (embryos with the correct chromosome complement).

 

What does the test analyse and what information will be provided?

The ERA test entails an analysis of 248 genes in the endometrium to detect endometrial abnormality. The results from the ERA test can indicate the optimal time for embryo transfer. Therefore, a personalised embryo transfer will be performed according to the personalised window of implantation.  This may increase the chance of reproductive success.

 

How is a sample collected?

A single sample of endometrium is obtained from the uterine cavity either in a natural cycle or in a medicated cycle. Your consultant will discuss the exact timing of when the endometrial sample will be taken.

 

What is the turnaround time for the test?

This is approximately 15 days.

 

What are the risks?

An endometrial sampling can be associated with small risk of bleeding and infection.

In approximately <1% of cases there is a “Non-informative” result. In those cases, a new endometrial biopsy could be required. There is a risk (<5%) that the biopsy procedure will fail to obtain a sufficient quantity and/or quality of tissue to be able to make a diagnosis. If this should occur, a new biopsy will be required.

 

 

EMMA

What is the test?

EMMA is a screening test to evaluate if the endometrial microbial environment is optimal for embryo implantation. EMMA provides a comprehensive view of the endometrial bacteria including healthy and unhealthy (pathogenic) bacteria. A healthy endometrium is rich is healthy bacteria such as Lactobacilli6. It has been shown that lower proportions of Lactobacilli in the endometrium are associated with poor reproductive outcomes in patients embarking on fertility treatment6.

 

What are the indications for EMMA?

EMMA can be beneficial for any patient wishing to conceive by assessing the microbiological (bacterial) environment of the endometrium. At CRGH, we offer the EMMA test to women who have experienced recurrent pregnancy loss or implantation failure with good quality or euploid embryos (embryos with the correct chromosome complement).

 

What are the benefits of the EMMA test vs microbial culture?

Microbial culture (growing bacteria in the lab) is the conventional method for identification of bacteria and infection. However, it has been shown that between 20-60% of bacteria cannot be cultured in the laboratory. The EMMA test uses advanced technology (next generation sequencing) to allow detection of culturable and non-culturable bacteria7.

 

How is a sample collected?

A single sample of endometrium is obtained from the uterine cavity either in a natural cycle (between days 15-25) or in a medicated cycle as per ERA protocol.

 

Do any drugs affect or interfere with the EMMA analysis?

Yes, particularly antibiotics. If you have taken antibiotics during the three months prior to the sample collection or any other medicine, please inform your doctor.

 

What is the turnaround time for the test?

This is approximately 15 days.

 

What information is provided?

The EMMA report will provide information about the overall microbial health of the uterine cavity. If the endometrium has an abnormal bacterial profile, an appropriate treatment will be recommended such as probiotic and antibiotic therapy.

 

Is a second sample required?

If a previous EMMA report was abnormal, a second sample is recommended following confirmation of recommended treatment. It is anticipated that up to 40% of patients may require a second sample.

 

What are the risks?

An endometrial sampling can be associated with small risk of bleeding and infection. In some cases, there is a “No-diagnosis” result, which could be due to bacterial DNA levels below the detection limit of the technique, sample degradation or sample contamination during collection or shipment. If this should occur, it will be assessed whether a new biopsy will be required.

 

  

ALICE

What is the test?

The ALICE test detects pathogenic bacteria that cause chronic endometritis.  By evaluating the endometrium at a microbiological level, we aim to improve the outcome for patients with chronic endometritis.

 

What is chronic endometritis?

Chronic endometritis is inflammation of the endometrium without any symptoms in most cases. It is mainly caused by bacterial infection. Chronic endometritis can affect up to a third of infertile women2. However, it can be the cause of two third of cases with repeated implantation failure or recurrent pregnancy loss8,9.

 

What are the indications for ALICE?

ALICE can be beneficial for any patient wishing to conceive by assessing the endometrial microbiological environment. At CRGH, we offer the ALICE test to women who have experienced recurrent pregnancy loss or implantation failure with good quality or euploid embryos (embryo with the correct chromosome complement).

 

What are the benefits of the ALICE test vs conventional methods?

The ALICE test gives equivalent results that are concordant with results obtained using combined histology (microscopic assessment of tissue), hysteroscopy (telescope procedure to assess the cavity of the womb) and culture6,7.

 

How is a sample collected?

A single sample of endometrium is obtained from the uterine cavity either in a natural cycle (between days 15-25) or in a medicated cycle as per ERA test protocol.

 

Do any drugs affect or interfere with the ALICE analysis?

Yes, particularly antibiotics. If you have taken antibiotics or any other medications during the three months prior to the sample collection or any other medicine, please inform your doctor.

 

What is the turnaround time for the test?

This is approximately 15 days.

 

What information is provided?

The ALICE report will provide information about the presence of specific bacterial that cause chronic endometritis. Other genital bacteria associated with sexually transmitted infections.

For any bacterial pathogens, antibiotic therapy will be recommended.

 

Is a second sample required?

If a previous ALICE report was abnormal, a second sample is recommended following confirmation of recommended treatment. It is anticipated that up to 40% of patients may require a second sample.

 

What are the risks?

An endometrial sampling can be associated with a small risk of bleeding and infection. In some cases, there is a “No-diagnosis” result, which could be due to bacterial DNA levels below the detection limit of the technique, sample degradation or sample contamination during collection or shipment. If this should occur, it will be assessed whether a new biopsy will be required.

 

 

NKT

Further information on Natural Killer Testing can be found here

 

Contact us

If you would like to book an appointment with one of our doctors you can:

  • Speak to the booking team on +44 (0)20 7837 2905  (Mon – Fri 8.30am – 6pm)
  • Email us on info@crgh.co.uk 
  • Visit our Appointments page, fill out the contact form and a member of the team will be in touch.

 

References:

  1. Jose A Miravet-ValencianoAlejandro Rincon-BertolinFelipe VilellaCarlos Simon. Understanding and improving endometrial receptivity Curr Opinion Obstet Gynecol 2015; 27: 187-92.
  2. J TanA KanJ Hitkari B Taylor N Tallon G WarraichA YuzpeG Nakhuda. The role of the endometrila receptivity array in patients who have failed euploid embryo transfers J Assist Reprod Genet 2018; 35:683-692.
  3. Maria Ruiz-Alonso1David BlesaPatricia Díaz-GimenoEva GómezManuel Fernández-SánchezFrancisco CarranzaJoan CarreraFelip VilellaAntonio PellicerCarlos Simón. The endometrial receptivity array for diagnosis and personalised embryo tranfer as a treatment for patients with repeated implantation failure. Fertil Steril 2013;100: 818-24.
  4. Nalini MahajanSimrandeep KaurMaria Ruiz Alonso. Window of Implantation is Significantly Displaced in Patients with Adenomyosis with Previous Implantation Failure as Determined by Endometrial Receptivity Assay. J Hum Reprod Sci. 2018;11:353-358.
  5. Ana Raquel NevesMarta DevesaFrancisca Martínez Sandra Garcia-Martinez Ignacio Rodriguez Nikolaos P Polyzos Buenaventura Coroleu. What is the clinical impact of the endometrial receptivity array in PGT-A and oocyte donation cycles? J Assist Reprod Genet 2019;36:1901-1908.
  6. 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.
  7. 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; 218: e1-602.e16.
  8. CicinelliE, Matteo M, Tinelli R, Pinto V, Marinaccio M, Indraccolo U, De Ziegler D, Resta L/Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment. Reprod Sci. 2014; 21: 640-7.
  9. CicinelliE, Matteo M, Tinelli R, Lepera A, Alfonso R, Indraccolo U, Marrocchella S, Greco P, Resta L.  Prevalence of chronic endometritis in repeated unexplained implantation failure and the IVF success rate after antibiotic therapy. Hum Reprod 2015; 30: 323-30.

IVF Packages With Access Fertility

IVF Packages With Access Fertility
CRGH is partnering with Access Fertility to offer a series of IVF programmes and packages. For more information please click below.

NHS Funding for Fertility Care

CRGH is an NHS approved centre and funding may be available for some patients. You will need to meet certain criteria and be referred to us by your GP. Please call or email us for further information.
Call: +44 (0)20 7837 2905

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