PRP, EMMA, ALICE & ERA — advanced IVF add-ons and the TCM view

By Dr (TCM) Attilio D'Alberto | Traditional Chinese Medicine Practitioner, Wokingham

On this page

1. Overview
2. ERA — endometrial receptivity array
3. EMMA — endometrial microbiome metagenomic analysis
4. ALICE — analysis of infectious chronic endometritis
5. PRP — platelet-rich plasma
6. A Chinese medicine view of implantation failure
7. How acupuncture helps
8. Chinese herbal medicine
9. Combining advanced add-ons with TCM preparation
10. Frequently asked questions
11. References

1. Overview

Patients who have had one or more failed IVF cycles — particularly cycles with good-quality embryos that have not implanted — are increasingly being offered a cluster of advanced tests and add-ons: ERA, EMMA, ALICE and PRP. These investigate and address the receptivity of the uterus rather than the egg or embryo. They are mostly available privately, and most commonly through European clinics (particularly in Greece, Spain and the Czech Republic) and a small number of London private clinics. In traditional Chinese medicine, the same clinical territory has been recognised for centuries as the “ability of the uterus to receive” — a function of uterine blood flow, warmth, freedom from stagnation, and adequate Kidney essence. The two frameworks complement each other well, and in my Wokingham clinic I see a growing number of patients combining advanced Western tests with acupuncture and Chinese herbal medicine to prepare the uterus for transfer.

2. ERA — endometrial receptivity array

The Endometrial Receptivity Array (ERA) is a molecular test developed by Igenomix that examines the gene expression profile of an endometrial biopsy taken during a mock cycle. It tests around 240 genes involved in the “window of implantation” — the brief period (typically 24–48 hours, on roughly day 19–21 of a natural cycle) during which the endometrium is biochemically receptive to an embryo.^[1]

The principle behind ERA is that around one in four women with repeated implantation failure has a displaced window of implantation. Their endometrium is receptive earlier or later than the standard transfer day, so a textbook day-5 blastocyst transfer arrives in a non-receptive uterus. The ERA biopsy is processed by Igenomix and returned as “receptive”, “pre-receptive” or “post-receptive”, with a recommendation to advance or delay transfer by a specific number of hours in the next cycle — a so-called personalised embryo transfer (pET).

ERA is most often considered for patients with two or more failed transfers of good-quality embryos. The biopsy is taken in a mock hormone replacement or natural cycle, after which the recommended timing is applied to the next real transfer. Critics point out that subsequent randomised trials have produced mixed results, with some failing to show benefit; supporters argue that the test identifies a specific subgroup who would otherwise continue failing.^[2] The clinical reality is that it is most useful as part of a wider workup — alongside EMMA, ALICE, hysteroscopy and immune testing — rather than as a single answer.

3. EMMA — endometrial microbiome metagenomic analysis

The EMMA test analyses the bacterial community of the endometrium itself. For many years it was assumed that the uterine cavity was sterile; modern molecular techniques (16S rRNA sequencing) have shown otherwise. The endometrium has its own microbiome, and the composition of that microbiome appears to influence implantation success.^[3]

A healthy endometrial microbiome is dominated (typically >90%) by Lactobacillus species, particularly L. crispatus. When Lactobacillus falls below this threshold and other bacteria predominate — a state called dysbiosis — implantation rates appear to fall and miscarriage rates appear to rise. EMMA reports the percentage of Lactobacillus in the endometrial sample and identifies the dominant non-Lactobacillus organisms when present.

Where dysbiosis is identified, EMMA results typically come with treatment recommendations: vaginal or oral probiotics weighted towards L. crispatus, and where pathogenic organisms are identified, targeted antibiotics. The biopsy used for EMMA can usually be combined with the ALICE and ERA samples in a single procedure, which is generally how it is offered clinically.

4. ALICE — analysis of infectious chronic endometritis

Chronic endometritis is a low-grade, often symptom-free inflammation of the endometrium caused by persistent bacterial colonisation. Estimates of prevalence in women with repeated implantation failure or recurrent miscarriage range from 15% to 30% — high enough that it is now regarded as a routine consideration in workup. The classical diagnosis is by hysteroscopy plus endometrial biopsy with CD138 immunohistochemistry to identify plasma cells. ALICE adds a molecular layer: it specifically identifies the bacterial species (Streptococcus, Enterococcus, Gardnerella, Mycoplasma, Ureaplasma, Klebsiella, Escherichia coli, Staphylococcus and others) most commonly responsible.^[4]

The clinical value of ALICE is that it tells the IVF clinician which antibiotic to use. Treatment is typically a 14-day course of doxycycline first-line, with second-line cover (metronidazole + ciprofloxacin, or another targeted combination) depending on what the test identifies. A repeat hysteroscopy or repeat ALICE biopsy after treatment is sometimes used to confirm clearance before the next embryo transfer.

ALICE is most often run together with EMMA on the same biopsy, with the combined report giving both the dysbiosis picture and the pathogen identification in one document.

5. PRP — platelet-rich plasma

Platelet-rich plasma is a concentrate of the patient’s own platelets, separated from a venous blood sample by centrifugation. Platelets are rich in growth factors — vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), transforming growth factor beta (TGFβ), epidermal growth factor (EGF) and many others — that are released when the concentrate is delivered into tissue. In fertility medicine PRP is used in two distinct ways:

• Intraovarian PRP — infused directly into the ovarian cortex under ultrasound guidance, usually transvaginally. It is used in patients with diminished ovarian reserve, poor responders, low AMH and premature ovarian insufficiency. Pilot studies and case series, particularly from Greek centres, report improvements in AMH, antral follicle count and pregnancy rates in carefully selected patients who would otherwise be advised toward donor eggs.^[5]
• Intrauterine PRP — infused into the uterine cavity (similar in technique to an embryo transfer) in the follicular phase of the cycle to support endometrial development. It is used primarily for thin endometrium and recurrent implantation failure. Randomised and observational data support improved endometrial thickness and clinical pregnancy rates in selected patients.^[6]

PRP is autologous — it uses the patient’s own blood — so the immunological risk is low. The evidence base is still maturing, larger randomised trials are needed, and not every patient responds. It is most useful when there is a clearly identified problem (thin lining, poor response, low AMH) and when it forms part of a wider preparation strategy rather than a stand-alone fix.

PRP is routinely offered in many Athens, Barcelona, Valencia and Prague clinics. In the UK it is available in a handful of London private clinics but is not part of NHS pathways and not routinely available outside London. See my broader article on why IVF varies between clinics, doctors and countries for context on the international landscape.

6. A Chinese medicine view of implantation failure

In traditional Chinese medicine the uterus is described as the “palace of the embryo” (Zi Gong), and successful implantation requires several conditions to be met simultaneously: adequate Kidney essence (Jing) to provide the substrate for new life, sufficient Blood (Xue) and Yin to build a thick and well-nourished lining, free movement of Qi to allow embedding without obstruction, sufficient warmth (Yang) to maintain the uterine environment, and absence of stagnation, damp or heat that would compromise the receiving function. The four advanced Western tests and treatments above each map cleanly onto one or more of these TCM frames:

• ERA — window of implantation displacement — in TCM language, this is a disorder of timing and rhythm: the Heart-Kidney axis that governs the menstrual cycle is out of phase, often due to long-term stress (Liver Qi stagnation affecting the Chong and Ren channels) or Kidney Yang depletion shifting the cycle. Restoring cycle rhythm with cycle-phase acupuncture and tonifying herbs may help support the natural alignment of implantation window with transfer.
• EMMA — endometrial dysbiosis — in TCM, an unhealthy endometrial environment most often reflects Damp-Heat or Damp-Cold accumulation in the Lower Burner, and underlying Spleen Qi deficiency that fails to transform and transport fluids cleanly. The same picture clinically often presents as chronic vaginal symptoms, recurrent thrush or bacterial vaginosis, and a thick or sticky tongue coating.
• ALICE — chronic endometritis — this fits the TCM pattern of latent Damp-Heat or Toxin in the uterus, and is often associated with a history of pelvic infection, retained products of conception, or chronic urogenital symptoms. The TCM treatment principle is to clear heat, resolve damp, and strengthen the Spleen and Kidneys after antibiotic treatment has cleared the active pathogen.
• PRP — thin endometrium or poor ovarian response — thin lining and poor response map directly onto Kidney Yin and Blood deficiency, often with poor uterine blood flow (Blood stasis or Yang deficiency reducing perfusion). The classic TCM approach is to nourish Kidney Yin, build Blood, and move Blood gently to improve uterine and ovarian perfusion. This dovetails clinically with what PRP is attempting to do biochemically.

7. How acupuncture helps

The strongest evidence for acupuncture in IVF is for peri-transfer acupuncture (sessions within 24 hours either side of embryo transfer, per the Paulus protocol)^[7] and for a 12-week pre-cycle preparation phase using cycle-phase acupuncture once or twice weekly. The mechanisms most commonly cited are improved uterine artery blood flow (demonstrated on Doppler ultrasound), modulation of the hypothalamic-pituitary-ovarian axis, regulation of stress hormones and downregulation of inflammatory cytokines.^[8]

For patients undergoing ERA, EMMA, ALICE or PRP specifically:

• For ERA: regular cycle-phase acupuncture in the months leading up to the mock and live cycle may help support a consistent ovulation pattern and reduce the variability in the cycle that contributes to window-of-implantation drift. After the personalised transfer timing is set, peri-transfer acupuncture is offered as usual.
• For EMMA: acupuncture is not a substitute for probiotic or antibiotic treatment, but supports the underlying Spleen-Kidney axis that governs fluid metabolism and immune balance — the terrain in which microbiome shifts back toward Lactobacillus dominance.
• For ALICE: acupuncture is used after the antibiotic course is complete, to clear residual damp-heat and strengthen the constitution. It is not a substitute for the antibiotic.
• For PRP: acupuncture is given in the follicular phase to improve uterine artery blood flow (in intrauterine PRP cases) or to support ovarian responsiveness (in intraovarian PRP cases). Treatment is timed around the PRP procedure, with sessions before and after the infusion and again before transfer.

8. Chinese herbal medicine

Individually prescribed Chinese herbal medicine is used in the 12-week preparation phase before stimulation and stopped during the stimulation phase itself to avoid any interaction with the IVF drugs. Herbs are commonly resumed once pregnancy is confirmed, to support implantation and early gestation. A meta-analysis of Chinese herbal medicine in female infertility found significantly improved pregnancy rates compared with conventional treatment alone.^[9]

The most relevant herbal strategies for the four advanced tests above include:

• Window-of-implantation issues (ERA) — rhythm-regulating formulas such as variants of Xiao Yao San (to move Liver Qi) and Liu Wei Di Huang Wan or You Gui Wan (to support Kidney) timed by cycle phase, to bring the cycle into a more consistent rhythm.
• Endometrial dysbiosis (EMMA) — Spleen-strengthening and damp-resolving formulas (Si Jun Zi Tang, Shen Ling Bai Zhu San, Wan Dai Tang as appropriate) to support the underlying fluid-metabolism terrain. Direct anti-microbial herbal action is not the goal — the probiotic and (where indicated) antibiotic side handles that.
• Chronic endometritis (ALICE) — after antibiotic clearance, heat-clearing and damp-resolving formulas (variants of Long Dan Xie Gan Tang or Yi Yi Ren-based preparations) followed by Kidney-nourishing tonification to restore the constitution.
• Thin lining or poor responder (PRP) — Blood-building and Kidney-nourishing formulas such as variants of Si Wu Tang and Liu Wei Di Huang Wan, often combined with gentle Blood-moving herbs (Dan Shen, Chuan Xiong) to support uterine perfusion. See also my detailed page on how to thicken the uterine lining.

Always work with a RCHM-registered herbalist, and always tell your IVF clinic what you are taking.

9. Combining advanced add-ons with TCM preparation

The practical sequencing I most often use with patients who are pursuing these advanced add-ons is roughly as follows.

Months -3 to -1 before the IVF cycle: weekly cycle-phase acupuncture, individually prescribed Chinese herbal medicine, dietary work (warming and Blood-building foods, reducing cold and raw items), supplements appropriate to the picture (vitamin D, omega-3, CoQ10, methylated B-complex, magnesium glycinate). If ERA, EMMA and ALICE biopsies are planned, they are taken during this window in a mock or natural cycle.

Treatment of identified issues: probiotics weighted toward L. crispatus for low Lactobacillus, targeted antibiotics for ALICE-identified organisms (under the supervision of the IVF clinician), PRP infusion(s) if indicated for thin lining or poor responder profile, hysteroscopy if structural issues are identified.

The IVF cycle itself: herbs are stopped at the start of stimulation. Acupuncture continues, typically twice weekly during stimulation. Peri-transfer acupuncture sessions are timed within 24 hours either side of transfer. Personalised embryo transfer (pET) timing follows the ERA recommendation if relevant.

Post-transfer through 12 weeks: gentle weekly acupuncture, individually prescribed pregnancy-safe Chinese herbal medicine resumed once pregnancy is confirmed, continued through the first trimester to support early pregnancy.

None of this guarantees an outcome — no fertility treatment can. What it does is layer multiple complementary strategies onto a single carefully-prepared cycle, which in clinical practice produces better results than any single intervention used alone.

10. Frequently asked questions

How many failed IVF cycles before considering ERA, EMMA and ALICE?

Most IVF clinicians consider these tests after two failed transfers of good-quality embryos, particularly if euploid (PGT-A-tested) embryos have failed to implant. Some patients elect to have the tests earlier, especially if travelling abroad for IVF where the tests are easier to incorporate into the workup.

Are ERA, EMMA and ALICE available on the NHS?

No. These tests are not part of NHS IVF pathways. They are available privately, most commonly through European clinics (Greece, Spain, Czech Republic) and a small number of London private clinics. The biopsies are processed centrally by Igenomix.

Can the three tests be done from one biopsy?

Yes — ERA, EMMA and ALICE can usually be combined in a single endometrial biopsy and returned as a combined report (sometimes packaged as “EndomeTRIO”). This is convenient and avoids three separate procedures.

What is the cost of these tests in the UK and abroad?

The combined ERA + EMMA + ALICE biopsy typically costs around £800–£1,200 in London private clinics, and somewhat less in European clinics. Intraovarian PRP cycles range from around £1,000–£2,500 per session; intrauterine PRP from around £500–£1,000 per cycle.

Does PRP work for low AMH or premature ovarian insufficiency?

Pilot studies and case series — particularly from Greek groups — report improvements in AMH, antral follicle count and pregnancy rates in carefully selected patients. Larger randomised data are still maturing. It is not appropriate for every patient, and the clinical picture (age, AMH, FSH, response history) should be reviewed by an experienced reproductive endocrinologist before proceeding. See also my page on low AMH levels.

Can I have acupuncture during a mock ERA cycle?

Yes — weekly cycle-phase acupuncture is appropriate through the mock cycle. The biopsy itself is a minor procedure and acupuncture either side of it is fine. The main consideration is to coordinate timing with the clinic's biopsy schedule.

Can I take Chinese herbs after a PRP infusion?

Yes — pregnancy-safe Blood and Kidney-nourishing herbs are commonly used through the cycle that follows a PRP infusion, to support the underlying perfusion and tissue-quality work that PRP is doing biochemically. Herbs are stopped at the start of stimulation as usual.

If chronic endometritis is identified by ALICE, do I have to take antibiotics?

Yes — antibiotics are first-line treatment for chronic endometritis once it is identified, and acupuncture and herbs are not substitutes for the antibiotic. They are used after the antibiotic course is complete, to restore the constitutional terrain.

If you have had one or more failed IVF cycles and are considering ERA, EMMA, ALICE or PRP, or if you are planning IVF abroad and want to prepare with acupuncture and Chinese herbal medicine, contact me or book a consultation at my Wokingham, Berkshire clinic.

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11. My Fertility Guide

12. References

1. Díaz-Gimeno P, Horcajadas JA, Martínez-Conejero JA, et al. A genomic diagnostic tool for human endometrial receptivity based on the transcriptomic signature. Fertility and Sterility. 2011;95(1):50–60.

2. Simón C, Gómez C, Cabanillas S, et al. A 5-year multicentre randomized controlled trial comparing personalized, frozen and fresh blastocyst transfer in IVF. Reproductive BioMedicine Online. 2020;41(3):402–415.

3. Moreno I, Codoñer FM, Vilella F, et al. Evidence that the endometrial microbiota has an effect on implantation success or failure. American Journal of Obstetrics and Gynecology. 2016;215(6):684–703.

4. Moreno I, Cicinelli E, Garcia-Grau I, et al. The diagnosis of chronic endometritis in infertile asymptomatic women: a comparative study of histology, microbial cultures, hysteroscopy, and molecular microbiology. American Journal of Obstetrics and Gynecology. 2018;218(6):602.e1–602.e16.

5. Sfakianoudis K, Simopoulou M, Nitsos N, et al. A case series on platelet-rich plasma revolutionary management of poor responder patients. Gynecologic and Obstetric Investigation. 2019;84(1):99–106.

6. Chang Y, Li J, Chen Y, et al. Autologous platelet-rich plasma promotes endometrial growth and improves pregnancy outcome during in vitro fertilization. International Journal of Clinical and Experimental Medicine. 2015;8(1):1286–1290.

7. Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertility and Sterility. 2002;77(4):721–724.

8. Manheimer E, van der Windt D, Cheng K, et al. The effects of acupuncture on rates of clinical pregnancy among women undergoing in vitro fertilization: a systematic review and meta-analysis. Human Reproduction Update. 2013;19(6):696–713.

9. Ried K, Stuart K. Efficacy of traditional Chinese herbal medicine in the management of female infertility: a systematic review. Complementary Therapies in Medicine. 2011;19(6):319–331.