Hi Dr. Sher, I love listening to you and first discovered you on the Dr. Aimee show! Thank you for all you have done and do in this field! I am 37 years old with 2 LB’s, AMH is 6.37mg/dl afc 24+. I have a history of recurrent chemical pregnancy, about 12-15. I have had 6 this year alone. I started seeing a RE earlier this year for the first time and she did a full RPL work up. Everything came back normal/good. My HSG showed my tubes are clear bilaterally and I have a normal shaped and sized anteverted uterus. My doctor told me to keep trying. I get pregnant almost every cycle I try and am fertile but I have issues with implantation clearly. I am taking Progesterone 200mg vaginally 1 x q pm starting 3dpo and baby aspirin. I requested an endometrial biopsy and it showed I have a bcl6 Hscore of 3.4 which suggest endometriosis. But the biopsy also found fragments of polyp in the sample. A polyp has never shown up on TSV US or my HSG but could a thickened endometrium during these procedures obscure visualization? I did the TSV US and HSG when they were evaluating one of my losses b/c my HCG level was rising abnormally and my lining was thickened. I ended up using methotrexate x 1 only for that loss. Nevertheless, My RE stated there can be a high false positive rate with evaluating evidence of a polyp through biopsy so she wasn’t interested in doing hysteroscopy but I suggested it any way. I will do that on my next cycle. If I knew to have asked for a Saline Sono hysterography, I would have done that instead of the biopsy, but I originally was concerned about endometritis and thought biopsy was the best diagnostic tool for that but have since also found I should do a microbiome test instead like Fertilysis to evaluate endometritis. My doctor seems more concerned with the elevated h score, endometriosis and it may contribute to RPL and evaluating interventions for it : Laparascopy or Depot Lupron and IVF. Based on this information I have a few questions,

1. How likely could the negative impacts of potential endometriosis, such as poorer egg quality have on RPL in my case? I don’t have any endometriomas, good reserve, clear tubes etc. It seems that more studies link endometriosis to infertility vs. RPL, specifically chemical pregnancy? I’m concerned if the issue is “seed vs. soil.” I am AMA now but I began having recurrent chemical pregnancy starting at 29 after my first child. I’ve had 1LB at 27 and another at 31 yrs old-natural cycles.
2. Is there an element of immunological factors associated with endometriosis in the uterine cavity at the window of implantation that could be causing RPL and is there anything I can do other than IVF to overcome these factors?
3.Can a small polyp(s) be missed on TSV US and would a small polyp interfere with implantation to this degree to cause multiple biochemcial pregnancy loss?

Thank you so much for your time!