EMMA and ALICE

What is EMMA (Endometrial Microbiome Metagenomic Analysis)?

The test is aimed to analyse the endometrial microbiome to help identify abnormalities associated with a poor reproductive prognosis.

 EMMA is a molecular tool used to determine whether the uterine microbial environment is optimal for endometrial health. This molecular method is based on detecting and measuring the amount of bacterial DNA present in the endometrial sample. 

Therefore, EMMA helps to determine when the endometrium presents a physiological bacterial flora. Lactobacilli accounts for less than 90% of the microbiotal in the endometrium which will lead to significantly decrease in pregnancy rate.

If the result comes back indicated “ ABNORMAL ENDOMETRIAL MICROBIOME” , doctors can provide appropriate probiotics suggested by the report for the patient to use in order to create a better endometrium environment for later implantation. 

Why use EMMA test?

• EMMA uses the latest Next Generation Sequencing (NGS) technology to provide endometrial microbiome information by analysing the complete profile of the bacteria present in the tissue

• EMMA can determine the percentage of Lactobacillus present in the endometrium; low proportions of Lactobacillus are associated with lower pregnancy rate. 

• EMMA includes the ALICE test, so it indicates the possible presence of bacteria that can cause chronic endometritis, further other pathogenic bacteria.

• If the endometrium is non-Lactobacillus dominated, the report will suggest the adequate treatment for each patient

• EMMA will determine whether the uterine microbial environment is optimal or not for embryo implantation

Who should use the EMMA?

•  Patients with repeated implantation failure (RIF)

• EMMA can be beneficial for any patient wishing to conceive, by assessing the microbiological environment that the embryo will encounter at implantation

How is EMMA done?

Doctors will use pipelle endometrial suction curette to go into the uterus through vagina, acquire a small amount of endometrium samples. The whole procedure takes around 30 seconds to 1 minute. 

 

What is ALICE (Analysis of Infectious Chronic Endometritis)?

Chronic endometritis(CE)will lead to endometritis which is one of the reasons for infertility and under most circumstances patients do not appear with obvious symptoms.ALICE is  a test that detects pathogenic bacteria and recommends adequate treatment. In traditional IVF, doctors can not diagnose the bacterias  specifically, and can not prescribe the appropriate treatment. 

ALICE is a diagnostic test to detect and quantify the most common 8 pathogenic bacteria causing chronic endometritis, recommending appropriate antibiotic and probiotic treatment

• -Enterobacteria (e.g. Escherichia, Klebsiella)

• -Chlamydia

• -Mycoplasma

• -Neisseria

• -Ureaplasma

• -Enterococcus

• -Streptococcus

• -Staphylococcus

※  In cases of repeated implantation failure or recurrent pregnancy loss, chronic endometritis can rise to 66%.

Who should use ALICE?

• ALICE can be beneficial for any patient wishing to conceive, by assessing the microbiological environment that the embryo will encounter at implantation.

• ALICE may also be beneficial for patients with a history of recurrent pregnancy loss or recurrent implantation failure because chronic endometritis has been linked to these events.

How is ALICE done?

Doctors will use pipelle endometrial suction curette to go into the uterus through vagina, acquire a small amount of endometrium samples. The whole procedure takes around 30 seconds to 1 minute, it can be done with an EMMA test.

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What is IUI?

Based on the prediction of ovulation, treated semen sample with higher concentration of sperms number would be injected into the uterine by the doctor.

 

Am I suitable for undergoing IUI?

·   Candidate: Who is under age 34, and acquire at least one patent fallopian tube.

·   Successful rate: 20~30%

·   Failed to conceive despite trying to get pregnant for more than at least 6 months.

Day 2 –Day 4: Ultrasound

Examine the antral follicles count(AFC) by trans-vaginal ultrasound(TVS). 

Day 2 –Day 4: Stimulation with injections and medicine

Hormone injections such as rFSH would be used to stimulate and regulate the formation of follicles.

rFSH

Short-term injection Puregon

Short-term injection Gonal-F

 

The relationship between injections and ovulation
The ingredient of injections is like the nutrition of the follicles. Your doctor will prescribe the most suitable medicine and dosage according to your current condition.

Day 8: Ultrasound and hormone blood testing
Evaluating the size and the growth of follicles by doing ultrasound and blood testing.

Day 11: Ultrasound
The size of follicles will be observed by TVS. (diameter >14 mm would be considered as median follicles, diameter >17 mm would be considered as big follicles.)

Day 12: Ultrasound and trigger

Trigger at night based on the size of follicles. The follicles will release the mature oocytes 36-40 hours after trigger.

r-hCG

Mimicking LH surge Ovidrel

 

Day 14: Insemination
The concentrated semen sample with better sperm quality would be transferred into the uterus by the doctor.

Rest after transfer
Lying for 30 minutes at least after transfer. Lift up the bottom to assist the sperms heading to fallopian tubes.

Day 14-31: Progesterone

Progesterone enhancement
To stabilize the endometrium, taking progesterone medicine for 15 days. During this period, your period would not come since we regulate your hormone by pills. If spotting recharge is observed, please contact the clinic as soon as possible.

Progesterone （Pills or vaginal suppositories）	Stabilize the endometrium Utrogestan
Aspirin	Boost circulation Bokey

Day 31: Pregnancy test
After stopping the medicine for 3 days, please make an appointment for pregnancy test. However, if your period comes in a week, the attempt of this cycle is failed.

The cost of IUI

Treatment	Injections/ultrasound/ hormone level	Semen sample preparation and transfer	Progesterone medicine
Cost(NTD)	10000~30000	9000~11000	500~3000

For reference only

FAQ

·  What if the IUI do not work out after 2-3 months’ attempts.

The working theory of IUI is relatively straight forward but not precise. Therefore, IUI is not recommended for women who acquire other complication such as abnormal uterine capacity or diminished ovarian reserve.

After trying for 3-6 months, please consult with your doctor and consider other approach such as IVF.

·   What can I do if the thought of taking shots by myself is too dreadful to me?
1．You could bring your injections to our centers. Nurses would assist the injection
2．Hold the prescription sign to our collaborated clinic。

·    What are the risks of IUI?
1．Since we stimulate the ovulation by extra hormone, multiple-birth pregnancy is more likely to occur.
2．The extra hormone might induce the overreaction of the ovaries. If the development of follicles is beyond prediction, your doctor might strongly suggest you to alter your treatment from IUI to IVF.

·    The risk of ovarian hyperstimulation syndrome(OHSS)
1．The cause of OHSS is the hormone injections for follicles stimulation, which would also lead to the increase of hormone level. The elevated hormone might cause the unbalance of osmotic pressure.
2．The symptoms of OHSS include abdominal pain, oliguria and shortness of breath.
3．Severe side effects might also include ascites. Please notify us if you have the symptoms above.

·         What should I do if I have bleeding during taking the Progesterone medicine?

Amount of bleeding	Less than a circle with a thumb and forefinger		Greater than a circle with a thumb and forefinger
Color
Act	No need to alter the prescription.	Take two extra progesterone supplements. Please rest in bed for 1-2 hours, and check if the recharge is eased or not.	Please use the early pregnancy medication packet ASAP. (Please also keep the original prescription prescribe by the doctor.)
Early pregnancy medication packet	Finish the Progesterone 25mg (2 Amp) injection and take 2 tranexamic acid capsules immediately. Come to our centers right away or hospitals in your neighborhood. If the following day is Sunday, please keep taking two tranexamic acid capsules after each meal, and return to the clinic on the following Monday.