A Note on ERA Testing: High Cost, Uncertain Benefit

Key Takeaways

The ERA test claims to find a personalized window of implantation. However, a large randomised trial (JAMA 2022) showed that it does not increase live birth rates. In recurrent transfer failure, embryo quality and uterine cavity evaluation take priority.

Key evidence: Doyle et al. — JAMA 2022 randomised trial (PMID 36472596) · NICE NG257 — Endometrial Receptivity Testing (2026) · ESHRE Good Practice Recommendations on RIF (2023)

In consultations I regularly meet patients who arrive with a quote from another centre. After two unsuccessful embryo transfers, they have been offered an ERA test, with biopsy fees, extra hormone treatment and a delayed transfer cycle.

The question they bring is almost always the same: will this test bring them their baby? It is an honest question, and it deserves an equally honest answer.

On this page

• What Does Scientific Evidence Say?
• What Questions Should We Ask First?
• An Ethical Reflection — Refusing Silent Compliance
• Is There a Case for ERA?
• Conclusion

What Does Scientific Evidence Say?

The Endometrial Receptivity Analysis (ERA) test hypothesizes that mapping gene expression in the uterine lining can identify a personalized “window of implantation” (WOI). The concept is elegant. The problem is that clinical evidence supporting its effectiveness has failed to materialize.

1. JAMA Randomized Controlled Trial (Doyle et al., 2022): Directly comparing personalized transfer timing via ERA against standard transfer timing found no significant improvement in live birth rates.
2. Hum Reprod Re-Analysis (Richter & Richter, 2023): Showed that ERA failed to identify the window of implantation and that ERA-guided personalised transfer actually reduced rather than increased birth rates; the authors argued that its clinical use should stop outside controlled research.
3. NICE (2026) & ESHRE Add-ons Guidance: NICE recommends not offering endometrial receptivity testing as a treatment add-on for embryo transfer (NICE NG257), and ESHRE states that the currently available endometrial receptivity tests are not recommended (ESHRE, 2023).

What Questions Should We Ask First?

When a patient experiences repeated transfer failures, my immediate clinical reflex is not to order an ERA test. In recurrent implantation failure, the true underlying cause is far more frequently found elsewhere:

1. Embryo Quality

Was the embryo cultured to the blastocyst stage? If genetic screening (PGT-A) was performed, was it conducted for a valid indication in a verified laboratory? Embryo developmental potential is the primary determinant of success.

2. Uterine Cavity Environment

Before molecular testing, visible anatomical and inflammatory factors must be thoroughly evaluated: hydrosalpinx (fluid-filled Fallopian tube), polyps, submucosal fibroids, or intrauterine adhesions. These can be detected and treated at a fraction of the cost of complex molecular panels.

3. Endometrial Preparation & Transfer Technique

Suboptimal hormone dosage, incorrect progesterone timing, a difficult transfer, or catheter displacement can compromise a cycle — issues no molecular biopsy can compensate for.

An Ethical Reflection — Refusing Silent Compliance

Over the past decade, a lucrative “add-on economy” has grown in reproductive medicine. Time-lapse imaging, embryo glue, intralipid infusions, stem cell infusions, and ERA testing share a common pattern: hope is marketed to patients, additional revenue is generated for clinics, while conclusive scientific proof remains waiting at the door.

This criticism is not directed at individual colleagues or clinics; it is a systemic reflection. Commercial pressure encourages both doctors and patients to ask: “Can we do one more thing?”

Yet good medicine often consists of having the discipline to refrain from performing an unproven test.

Is There a Case for ERA?

I do not recommend ERA testing under any circumstances. The largest randomised trial found no improvement in live birth, NICE advises against offering it, and ESHRE does not recommend the currently available tests.

Conclusion

My answer to that question is that current evidence shows it does not. Before anything else, we should evaluate embryo quality, the anatomy of the uterine cavity and the transfer protocol.

The aim is a clear diagnostic plan designed around the patient’s own biology, not one sold to her anxiety.

Sources

• Doyle N, et al. Effect of Timing by Endometrial Receptivity Testing vs Standard Timing of Frozen Embryo Transfer on Live Birth…. JAMA. 2022;328(21):2117-2125.
• Richter KS, Richter ML. Personalized embryo transfer reduces success rates because endometrial receptivity analysis fails to accurately identify the window of implantation. Human Reproduction. 2023;38(7):1239-1244.
• NICE. Fertility problems: assessment and treatment (NG257). 2026. Recommendation 1.41.1.
• ESHRE Add-ons Working Group. Good practice recommendations on add-ons in reproductive medicine. Human Reproduction. 2023;38(11):2062-2104. doi:10.1093/humrep/dead184
• ESHRE Working Group on Recurrent Implantation Failure (Cimadomo D, et al.). ESHRE good practice recommendations on recurrent implantation failure. Human Reproduction Open. 2023;2023(3):hoad023.

Dr. Senai Aksoy

Dr. Senai Aksoy studied and trained in France before returning to Turkey, where he was a member of the ICSI team at Sevgi Hospital, Ankara — the country's first ICSI centre (1994-95) — and a co-author on the first Turkish ICSI publications produced in collaboration with the Brussels Van Steirteghem group (Human Reproduction, 1996; PMID 8671323). He helped build the IVF programme at the American Hospital Istanbul and has been running his own fertility practice since 1998.

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The content has been created by Dr. Senai Aksoy and medically approved.