Ovulation and hypothyroidism: The request could not be satisfied
Hypothyroidism and Fertility | IVF Experts
Hypothyroidism occurs when the thyroid gland is not producing as much thyroid hormone as it should. Hypothyroidism is common in women of reproductive age.
Depending on its severity, hypothyroidism may cause a variety of symptoms and may affect all body functions. In mild cases, there may be no symptoms at all. In more severe cases, the body’s metabolism slows, causing mental and physical sluggishness and a variety of other symptoms. In women of reproductive age, hypothyroidism can be a cause for failure to ovulate or failure to ovulate regularly. This, in turn, causes a woman’s periods to occur less frequently (oligomenorrhea) or to stop completely (amenorrhea).
A common cause of hypothyroidism is the presence of elevated levels of anti-thyroid antibodies. Failure of the pituitary gland to secrete a hormone (TSH or thyroid stimulating hormone) to stimulate the thyroid gland (secondary hypothyroidism) is a less common cause of hypothyroidism. Other causes include congenital defects, surgical removal of the thyroid gland, irradiation of the gland, or inflammatory conditions.
In an otherwise healthy woman, hypothyroidism can be easily detected by assessing the levels of TSH in the blood. A high TSH level indicates hypothyroidism. A slightly elevated level indicates a very mild case. A higher number indicates more severe disease and is often accompanied by a reduction in the level of T3 or T4 in the blood.
An elevated TSH with a normal T3 and/or T4
Overt or clinical hypothyroidism:
An elevated TSH and a low T4 and/or T3
Hypothyroidism and ovulation problems
Hypothyroidism can cause anovulation (failure to ovulate) directly or by causing elevation in another hormone called prolactin. Prolactin is the hormone used by the body to assist with lactation (milk production) after delivery. If a woman’s prolactin is elevated, she may experience milk discharge from her breasts (galactorrhea).
Treatment with oral thyroid hormone supplements (Synthroid, Levoxyl) will often correct the hypothyroidism and result in a return to normal ovulation and regular menstrual cycles. If prolactin levels were also elevated, then treatment usually results in a return of this hormone to normal levels with cessation of the breast discharge.
Once the thyroid is corrected, and ovulation is occurring, fertility is usually very good, unless there are other independent factors.
Hypothyroidism and miscarriage
A 2002 study of women with both clinical and sub-clinical hypothyroidism in early pregnancy found that the miscarriage rate was higher in both groups and that treatment with thyroid hormone could reduce the miscarriage risk.
Miscarriage risk may also be higher in women with anti-thyroid antibodies.
Hypothyroidism in pregnancy
It is extremely important to diagnose and treat clinical hypothyroidism in early pregnancy. The developing fetus cannot make its own thyroid hormone until about the 10th week of gestation. During this time, it relies on thyroid hormone production from the mom. Severe hypothyroidism is pregnant women, particularly in the 1st trimester, is associated with a host of pregnancy complications including pre-eclampsia (high blood pressure of pregnancy), placental abruption (separation of the placenta from the wall of the uterus), preterm birth, low birth weight and even fetal death. The babies can suffer from neurologic impairment, mental retardation, and intellectual impairment during childhood.
Fortunately, because women with hypothyroidism don’t usually get pregnant, clinical hypothyroidism in pregnancy is very rare, maybe occurring in 1 in 5000 pregnancies.
A study presented in 2007 did not find any difference in the chances for IVF success if women had untreated sub-clinical hypothyroidism at the beginning of their IVF cycle.
Sub-clinical hypothyroidism in pregnancy
If a woman has only a mild elevation in her TSH and her T4 and T3 levels are normal, there is disagreement about whether these pregnancies are at any higher risk. Sub-clinical hypothyroidism is a bit more common, occurring in 2-5% of all pregnancies. Some studies have suggested that the children born may have lower IQ scores or impaired psychomotor development. These studies, which were small and often didn’t distinguish between clinical and sub-clinical hypothyroidism are difficult to interpret.
Very recently, researchers published results of the largest study to date of the effects of sub-clinical hypothyroidism on pregnancy. They screened 25,756 pregnant women and found 404 (2.3%) met the criteria for the diagnosis of sub-clinical hypothyroidism. The pregnancies in these women were 3 times more likely to be complicated by placental abruption and twice as likely to have preterm birth. The proportion of infants admitted to the neonatal intensive care unit, as well as those who developed respiratory distress syndrome (a common problem in premature infants) was doubled.
It is not yet known whether treatment of sub-clinical hypothyroidism will reduce these risks though it seems reasonable to think for now that it would.
Is An Underactive Thyroid Preventing You Getting Pregnant?: A Path to Natural Health: Naturopathic Doctors
This series of articles is looking at fertility and how naturopathic medicine can help improve it if you are having difficulty conceiving. This time, I want to look at the role the thyroid gland can play in infertility. If you have missed any of the previous articles in this series and would like to catch up you can find them here:
- Sowing a Seed: Improving Fertility with Seeds and Oil
- Fertility & Folic Acid: Why Taking Folic Acid May Not Be Enough
- Wanting To Get Pregnant? Don’t Forget About Sperm Health
- What Is PCOS And How Does It Affect My Fertility?
The primary function of the thyroid gland is to produce hormones to regulate your metabolism, however it also plays an important role in female and male fertility and pregnancy by:
- Thickening the uterine lining for the fertilized egg to attach to
- Increasing body temperature to aid ovulation
- Helping with cell differentiation which is needed for a rapidly developing fetus
- Facilitating brain development in the fetus
- Helping to maintain healthy testosterone levels in males
- Helping with the production of the right quantity of high quality sperm
When thyroid hormone levels are too high or too low the following pregnancy risks can occur:
- Increased risk of miscarriage
- Poor fetal development
- Increased risk of premature birth
A malfunctioning thyroid gland can either be underactive (hypothyroid) or overactive (hyperthyroid). Of the two, hypothyroid can be harder to diagnose and the signs and symptoms can be more subtle and less obvious than those related to hyperthyroid; because of this hyperthyroid symptoms are less often overlooked. For this reason, in this article I will focus on the underactive hypothyroid condition; however, I will review hyperthyroid symptoms for comparison.
The Thyroid and Fertility
The thyroid plays a pivotal role in fertility for both men and women but, since thyroid conditions are more common in women than men, fertility issues resulting from a thyroid imbalance are also more common in women. In fact, many people who struggle with infertility go undiagnosed with hypothyroid.
The thyroid gland is part of the endocrine system and, along with the ovaries and adrenal glands, its job is to control the hormones in our body. These hormones are responsible for communication between the brain and our organs and tissues. The thyroid gland produces thyroid hormone whose primary role is energy metabolism. It also regulates weight, memory, focus and temperature. In addition to the above metabolic functions, thyroid hormone also has an influence on the reproductive system and plays a role in fertility and the health of the developing baby.
In males, too much thyroid hormone (an overactive thyroid) affects testosterone levels, causes low sperm count and low motility of sperm – not enough healthy, strong swimmers will decrease fertility. In males with hypothyroid, testosterone levels, semen quality and volume are reduced and sperm morphology, quality and motility are decreased. To read more about healthy sperm you can refer to the article, Wanting To Get Pregnant? Don’t Forget About Sperm Health.
In women with an overactive thyroid, the main risk is with the developing fetus. There is poor fetal development and, because of that, an increased risk of miscarriage and premature birth.
For women with hypothyroid, a decrease in body temperature affects ovulation and the quality of the uterine lining which is needed for a fertilized egg to attach to (implantation) – 2 key factors in infertility. Thyroid hormone is also essential for cells to properly divide, crucial for rapidly dividing fetal cells. Basically, if we do not have enough thyroid hormone the developing fetus inside the uterus will not grow properly and there is an increased risk of miscarriage.
How Can I Tell if I have a Thyroid Imbalance?
If you have been struggling to conceive and physicians are unable to give you a satisfactory reason why this is, it might be worth looking to your thyroid to see if that is the cause of your unexplained infertility. Many people walk around for years with an underactive thyroid and don’t even know it so the first thing to do is look at the following list of signs and symptoms that may be caused by thyroid problems to see whether you are experiencing any of them before going to your doctor and asking to be tested:
Signs of an Underactive or Overactive Thyroid
- Female Infertility
- Male Infertility
- Hair loss
- Dry skin
- Brittle nails
- Brain fog
Signs of an Underactive Thyroid
- Cold body temperature
- Weight gain or inability to lose weight
Signs of an Overactive Thyroid
- Increased body temperature
- Increased appetite and possible weight gain as a result
- Weight loss
- Racing heart / Palpitations
- Vision changes or bulging eyes
Testing – How Can I Be Sure My Thyroid Is Functioning Optimally?
If you are feeling frustrated that you have not been able to get pregnant or if you have talked to your doctor or fertility specialist and still been given no answers to why you cannot conceive then, your fertility struggles could be caused by hypothyroid. In fact, even if you’ve been told numerous times that your thyroid is fine you could still have an underactive thyroid. Let me explain.
It all comes down to the training of your physician.
Progressive-thinking physicians have been trained to read the whole picture of the person, all their symptoms, their basal body temperature and their thyroid labs. When your physician takes all of these variables into account then you may find an underactive thyroid gland as the cause of your infertility. Unfortunately many practitioners only look at a single lab value – TSH (thyroid stimulating hormone) – before making a decision about your endocrine system. This is why the diagnosis of hypothyroid gets overlooked for so many people.
If you are preparing for pregnancy or struggling with infertility it is important to understand what type of thyroid testing you should have done. Here is a complete list of thyroid lab testing I do on all of my patients, not just for fertility purposes, and the ranges that indicate that your thyroid is functioning normally. You may find your physician hesitant to run all of these labs and therefore you will need to find a physician who is familiar with, and willing to run, them all:
- TSH (Thyroid stimulating hormone) – normal range 0.450-2.0 uIU/ ml
- Free T3 (Triiodothyronine) – normal range 2.0-4.4 pg/ml
- Free T4 (Thyroxine) – normal range 0.82-1.77 ng/dl
- Reverse T3 – normal range 9.2-24.1 ng/ dl
- Anti-thyroglobulin antibodies – normal range 0-0.9 IU/ml
- Anti-thyroid peroxidase antibodies – normal range 0-34 IU/ ml
The problem with using TSH as the only screening or monitoring tool for an underactive thyroid is that different physicians read the range differently. As a Naturopathic physician I was always told that a TSH of 2 or under, with symptoms of low thyroid, should be treated as hypothyroid. However as you can see above, the normal range on labs is 0.450-4.5 uIU/ ml so, if someone had a TSH of 2.5 or 3 they may be told their thyroid is normal when in fact they are hypothyroid.
Free T3 and Free T4 have tight parameters and are a good gauge of circulating levels of thyroid hormone. Reverse T3 reflects the ability to convert T4 into active T3 so, if reverse T3 is high then you may not have enough active thyroid hormone.
Autoantibodies should either be not present at all or in very low in the case of anti-thyroid peroxidase antibodies. If they are present in high amounts but TSH, Free T3 & Free T4 are all within normal limits then you should monitor your thyroid labs yearly.
In addition to labs testing, basal body temperature (BBT) can be used to assess thyroid hormone function. This is based on Wilson’s Thyroid Protocol, developed by Dr Wilson M.D. In Wilson’s Thyroid Protocol you do not use blood levels to determine if your thyroid is under functioning or hypothyroid, you take your BBT 3 times a day and, if the average of those three readings is below 98.6 F then you likely have an underactive thyroid. Wilson’s Thyroid Treatment Protocol uses the active form of thyroid hormone T3 to reset the thyroid gland and should be done under the care of a trained Wilson Thyroid specialist.
I Suspect I have a Thyroid Condition – What Can I Do?
When diagnosed with hypothyroid, most people start taking prescription thyroid hormones. There are few pharmaceutical options:
- Armour Thyroid
Desiccated pig thyroid and contains both T3 & T4 hormone
Contains T3 hormone
Contains T4 hormone
Many people with borderline thyroid lab results are however, hesitant to start thyroid hormone and want to know what they can do before starting pharmaceutical replacement. The following is a list of the nutrients used to support the thyroid gland and help with thyroid hormone production. Before starting any treatment, I recommend you check with your physician to determine the best course of treatment for you:
- Iodine (as Potassium Iodide)
- Selenium (as Selenomethionine)
- Vitamin C (as Ascorbic Acid)
- Vitamin E (as d-Alpha Tocopheryl)
- Vitamin B12 (as Methylcobalamin)
- Zinc (as Zinc Picolinate)
- Copper (as Copper Picolinate)
- Ashwagandha extract (root) (Withania somnifera)
If you are thinking about getting pregnant or have been trying to conceive with no success and you have any of the thyroid signs and symptoms listed above then I recommend you ask your physician to do a thorough thyroid evaluation. Increasing your fertility could be as simple as adding thyroid hormone or even adding vitamins and minerals to support your thyroid hormone.
In my years of practice I have seen many women struggling with fertility who managed to conceive shortly after beginning thyroid hormone and some of these women did not even need to stay on the thyroid hormone after they delivered their baby. I have changed many people’s lives by diagnosing and treating their underlying hypothyroid condition.
Over and over again I hear people wondering why their hypothyroid condition wasn’t diagnosed earlier by another physician. Many people know there is something off with their body but they are not able to figure out what it is. So if you have been struggling with infertility please make sure your thyroid is working properly.
If you would like to have your thyroid tested or would like to work with me on your fertility, find out more information about my fertility package.
Join me next time when we will explore the role of adrenal stress in infertility.
Top 10 Facts About Thyroids & Fertility
The thyroid is a butterfly-shaped gland in the base of your neck just below the Adam’s apple. It produces several hormones, all of which play an important role in your body’s metabolism– and your fertility.
This post covers the top ten ways your thyroid can impact your ability to get and stay pregnant– particularly hypothyroidism (the most common thyroid disorder).
1. T4 Hormone Levels are Key
The most important hormone created by the thyroid gland is thyroxine (T4), which controls the body’s metabolism.If there is too much (hyperthyroidism) or too little T4 (hypothyroidism), the body does not function normally.
2. Thyroid Disorders are Quite Common
According to The Thyroid Foundation of America, there are as many as 8 million women in America with untreated thyroid disorders (about 1% of women). For those of reproductive age, infertility or miscarriage may be the first sign that something is wrong.
3. Hypothyroidism Slows the Metabolism
3) What are the symptoms of hypothyroidism? The slowed-down metabolism associated with hypothyroidism can manifest as fatigue, dry skin, constipation, heavier periods, weight gain, decrease in appetite, lethargy, depression, cold intolerance, or muscle aches.
4) How Hypothyroidism Causes Infertility
- Hypothyroidism can cause infertility by preventing ovulation—even when menstrual periods are occurring regularly.
- Women with undiagnosed hypothyroidism who do conceive have an elevated risk of miscarriage. And even hypothyroid women who’ve already been diagnosed, treated, and stabilized with medication need to be monitored closely.
- Some women with an underactive thyroid may experience elevated levels of prolactin, the hormone that induces the production of breast milk in postpartum women. Excess prolactin can make conceiving more difficult, again by preventing ovulation.
- Hypothyroidism’s effects on metabolism can also bring on a condition known as luteal phase defect. The luteal phase is the second half of the monthly cycle, lasting from ovulation to menstruation. It is normally 12 to 16 days long. But if the luteal phase chronically runs shorter than ten days, then there will be fertility problems since the uterine lining can’t build up sufficiently for the embryo to implant, and it will be flushed from the body with the next menstrual period.
5) How Hypothyroidism is Diagnosed
A simple blood test to measure thyroid stimulating hormone (TSH) level is used to diagnose hypothyroidism. TSH works like a thermostat; it’s produced by the pituitary gland to regulate thyroid function. An elevated TSH level is used to diagnose hypothyroidism. It indicates that the pituitary gland is attempting to compensate for an underactive thyroid gland.
6) Hashimoto’s Thyroiditis and Slow Thyroid Function
There’s also a blood test that checks for the presence of anti-thyroid antibodies. High levels of these antibodies are typical of a thyroid disease called Hashimoto’s Thyroiditis, which always results in hypothyroidism. Hashimoto’s Thyroiditis is classified as an autoimmune disease, because the body has essentially turned against itself, forming antibodies that attack the cells in the thyroid and slow down production of thyroid hormone. The gland itself may compensate by becoming enlarged.
7) Sub-Clinical Hypothyroidism Impacts Egg Quality
Sub-clinical hypothyroidism means that there are no symptoms. The only way of diagnosing this condition is with a blood test (TSH level). With elevated TSH levels, the quality of eggs retrieved is compromised. This results in lower pregnancy rates. It is therefore important that the TSH level be normalized prior to an IVF cycle.
8) Treating Hypothyroidism is Simple
To regulate thyroid levels, we prescribe oral synthetic thyroid tablets (Synthroid, Levoxyl, Levothyroxine). The goal is to treat with the lowest effective dose to maintain the TSH level close to (or just below) 2. 5. While establishing the correct dose can be quite easy in some individuals, others will fluctuate up and down before stabilizing.
9) You Need 30 – 50% More TSH During Pregnancy
TSH levels should be checked every 3 months during pregnancy and annually thereafter. During pregnancy, an endocrinologist or an obstetrician that’s familiar with thyroid issues should monitor blood levels closely. Uncorrected hypothyroidism can result in stillbirth. I will often tell patients that taking their thyroid pill is as important (if not more) as taking their vitamins!
10) Thyroid Disorders are Easy to Correct For
The good news is that among the various threats to fertility, thyroid disorders are arguably the easiest to identify and treat.
|Puberty and menstruation||Thyroid disorders can cause puberty and menstruation to occur abnormally early or late. In addition, abnormally high or low levels of thyroid hormone can cause very light or very heavy menstrual periods, very irregular menstrual periods, or absent menstrual periods (a condition called amenorrhea).|
|Reproduction||An overactive or underactive thyroid may also affect ovulation. This is the release of an egg for fertilization. Thyroid disorders may prevent ovulation from occurring at all. In addition, the ovaries are at an increased risk for cyst development if the woman has an underactive thyroid (hypothyroid). Severe hypothyroidism can actually cause milk production in the breast, while preventing ovulation.|
|Pregnancy and postpartum||Thyroid disorders during pregnancy can harm the fetus and may lead to thyroid problems in the mother after birth, such as postpartum thyroiditis. A deficiency of thyroid hormone can cause miscarriages, preterm delivery, stillbirth, and postpartum hemorrhage. Women with overactive thyroid during pregnancy are at risk of having more severe morning sickness. Ways of treating overactive thyroid gland during pregnancy must be individually considered.|
|Menopause||Thyroid disorders may cause the early onset of menopause (before age 40 or in the early 40s). Some symptoms of overactive thyroid (hyperthyroidism) may also be mistaken for early menopause. These include lack of menstruation, hot flashes, inability to sleep (insomnia), and mood swings. Treating hyperthyroidism can sometimes ease symptoms of early menopause or prevent early menopause from happening.|
Thyroid and infertility in women
According to a Harvard Medical School study, having even a slightly underactive thyroid may interfere with a woman’s ability to get pregnant. More than a quarter of the women in the study who had unexplained infertility showed signs of a thyroid gland performing at low-normal levels. Those women were about twice as likely to have higher levels of thyroid-stimulating hormone (TSH) than women who did not conceive due to known issues with their male partner’s sperm count.
Women are more likely than men to have thyroid disease and one in eight women will develop thyroid problems during her lifetime.
In women, thyroid disease can cause:
- Problems with your menstrual period: Your thyroid helps control your menstrual cycle. Too much or too little thyroid hormone can make your periods very light, heavy, or irregular. Thyroid disease also can cause your periods to stop for several months or longer, a condition called amenorrhea. If your body’s immune system causes thyroid disease, other glands, including your ovaries, may be involved. This can lead to early menopause (before age 40).
- Problems getting pregnant: When thyroid disease affects the menstrual cycle, it also affects ovulation. This can make it harder for you to get pregnant.
- Problems during pregnancy: Thyroid problems during pregnancy can cause health problems for the mother and the baby.
Sometimes, symptoms of thyroid problems are mistaken for menopause symptoms. Thyroid disease, especially hypothyroidism, is more likely to develop after menopause.
Both hyperthyroidism and hypothyroidism can make it harder for you to get pregnant. This is because problems with the thyroid hormone can upset the balance of the hormones that cause ovulation. Hypothyroidism can also cause your body to make more prolactin, the hormone that tells your body to make breastmilk. Too much prolactin can prevent ovulation.
Hyperthyroidism that is not treated with medicine during pregnancy can cause:
- Premature birth (birth of the baby before 39 to 40 weeks, or full-term).
- Preeclampsia, a serious condition starting after 20 weeks of pregnancy. Preeclampsia causes high blood pressure and problems with the kidneys and other organs. The only cure for preeclampsia is childbirth.
- Thyroid storm (sudden, severe worsening of symptoms).
- Fast heart rate in the newborn, which can lead to heart failure, poor weight gain, or an enlarged thyroid that can make it hard to breathe.
- Low birth weight (smaller than 5 pounds).
Hypothyroidism that is not treated with medicine during pregnancy can cause:
- Anaemia (lower than normal number of healthy red blood cells).
- Low birth weight (smaller than 5 pounds).
- Problems with the baby’s growth and brain development.
The epidemiology of thyroid diseases in the Arab world: A systematic review
Westernization and nutrition transition in Arab world have increased the burden of adenocarcinomas, including thyroid cancer. This review aims to present the aggregated burden, risk factors and prognosis of various thyroid diseases prevalent in Arab countries.
An electronic databases search was conducted using PubMed in addition to searching of accessible local journals in Arab world, using keywords and terms like epidemiology, burden, odds, risks, etc. After applying exclusion and inclusion criteria, 21 articles were selected to include in this review.
The review showed that the prevalence of different types of thyroid disease varied between the reported studies in Arab world ranging from 6.18 to 47.34% prevalence of goiter reported by several studies conducted in Arab world, such as Egypt, Algeria and Bahrain with 25.25, 86 and 1.7%, respectively.
Gender, dietary factors, iodine deficiency, family history, diabetes and x-ray radiation were reported as risk factors associated with different type of thyroid diseases. The most prevalence of thyroid disease was concluded to be thyroid lesions which varied in different regions of Arab and the burden of thyroid cancer is very high and very common in different Arab region, and further longitudinal studies are still needed to investigate the prognosis and determinants of these thyroid diseases in the Arab world.
‘Secondary infertility’ rates in the UAE are among the highest in the world, which is causing a massive decline in the country’s population and the population will continue to rapidly drop if changes are not made, warn doctors.
There is a significant drop in the number of children born in the UAE and this has a huge impact on the total population, and increasing the case of IVF. The number of births in the UAE is anticipated to drop to 1.66 per couple from 2020-2025. According to the Dubai Health Authority (DHA), around 50 per cent of the women face infertility issues. Statistics also reveal that women in Dubai seeking treatment per year could nearly double, from 5,975 in 2015 to 9,139 by 2030.
Hashimoto’s thyroiditis and PCOS: Is There a Connection?
Hashimoto’s disease: Illustration showing antibodies attacking thyroid gland
If you have been diagnosed with polycystic ovary syndrome, or PCOS, you are well aware that one the tell-tale sign is that your hormone levels are out of balance. Common symptoms include menstrual irregularity, problematic acne, and excessive hair growth. You may also struggle with your weight due to the disruptions that PCOS causes to your metabolism, and you may have difficulty getting pregnant.
Hashimoto’s thyroiditis, an autoimmune hypothyroid condition in which the body’s immune system attacks the thyroid—is three times more common in women with PCOS than in women without it.
If you are a woman with PCOS, your body may be producing too much androgen. Androgens are a class of male sex hormones, in particular, testosterone, that are found in smaller but necessary levels in women too. Higher levels of androgen may interfere with a woman’s ability to get pregnant; for this reason, many women with PCOS struggle with infertility.
Surprisingly, the researchers found that high levels of androgen are less common in patients who have both conditions: Hashimoto’s thyroiditis and PCOS. This hormone pattern was confirmed even when looking at testosterone alone–an increased testosterone level is not found in patients with both conditions.
Ovaries in thyroid hormone
In the presence of hypothyroidism, ovarian morphology becomes polycystic. Hence, thyroid disorders are one of the exclusion criteria before making a diagnosis of PCOS in any women.
Rise in thyrotropin-releasing hormone (TRH) in primary hypothyroidism leads to increased prolactin and thyroid stimulating hormone (TSH). Prolactin contributes toward polycystic ovarian morphology by inhibiting ovulation as a result of the change in the ratio of follicle stimulating hormone (FSH) and luteinizing hormone and increased dehydroepiandrosterone from the adrenal gland. Increased TSH also contributes due to its spill-over effect on FSH receptors. Increased collagen deposition in ovaries as a result of hypothyroidism has also been suggested.
Hypothyroidism, PCOS and sex hormone binding globulin
Now, there is something else that we need to consider. We know that women with POCS tend to have lower levels of SHBG. This is problematic because SHBG picks up free testosterone in the blood and helps to make it inactive. So, the less SHBG you have, the more testosterone you have to make your PCOS symptoms worse.
Here’s the thing, it is our thyroid hormones that increase the levels of SHBG. So, if you do have a sluggish thyroid, you will have a harder time getting your PCOS under control. Now that we know that there is this strong link, what should we do about it? Well, there are a couple of things. It’s really important that we all have our thyroid function monitored. My doctor runs blood tests every two years or so to monitor my general health and PCOS and thyroid function is included in this.
Treatment for thyroid disorders
If you suspect that you may have a thyroid disorder or your blood work shows an anomaly in your thyroid hormones, there is medical treatment available. Your doctor will guide you on this.
Diet and thyroid disorders
Once again, we come back to the cornerstone of PCOS Diet Support. Your diet can impact on your thyroid health, as well as your PCOS. Here are some suggestions to support your thyroid function and improve your PCOS:
Avoid soy: Soy products contain phytoestrogens that have been shown to increase the risk of developing subclinical hypothyroidism. Soy can also cause delayed ovulation which is why I don’t recommend soy products as part of a good PCOS Diet.
Give up Gluten: There is a protein in gluten (gliadin) that is very similar in structure to a thyroid hormone. So, if you have a gluten sensitivity, your body not only attacks the gliadin, it can also attack your thyroid in an autoimmune response.
Avoid sugar: Research has shown that hypothyroidism can make insulin resistance worse. And, eating sugar or highly refined carbs causes your body to release more insulin. Remember that all of this insulin is also causing your ovaries to release more testosterone. So, by avoiding highly processed and sugary foods, you are managing your PCOS and supporting your thyroid function.
We’ve established that women with PCOS are 22.5% more likely to have some type of thyroid dysfunction. This can make our PCOS symptoms worse and much harder to manage.
I highly recommend that you have your thyroid levels checked at least every two years. Following a good PCOS diet will not only help to manage your PCOS, it will also support your thyroid health.
Thyroid, Prolactin and Low FSH
Thyroid, Prolactin and Low FSH
Did you know that your thyroid and other glands play important roles in your sexual hormones, performance and fertility? Learning how these work and what tests can affect your chances for pregnancy helps you combat infertility. Understanding your reproductive hormones is a first step on your path to a successful outcome.
Thyroid and Pregnancy
Your thyroid depends on your pituitary gland to produce thyroid-stimulating hormones (TSH) that are important to keep your body’s menstrual cycles in rhythm and ovulating correctly. High TSH has been linked to infertility in women. (2). Additionally, infertile women are shown to have higher prolactin levels that can also contribute to abnormal ovulation patterns.
For your thyroid to run smoothly it needs to be functioning normally. If you have an underactive thyroid gland, you have to little thyroid hormone in your bloodstream and it is known as Hypothyroidism. It has been reported that women with hypothyroidism have significantly higher levels of prolactin as compared to those with hyperthyroidism,
If your body produces too much thyroid hormone, thyroxine, it is known as an overactive thyroid or Hyperthyroidism. With this condition, your body is running at a high metabolic rate that may lead to weight loss and rapid heart rate.
Both Hyperthyroidism and Hypothyroidism can negatively impact your reproductive processes. It is important to be tested for these conditions in your fertility evaluation at Inovi.
Prolactin and Your Menstrual Cycle
Prolactin also called luteotropic hormone is made in the pituitary gland of your body. This hormone is responsible for production of breast milk in females and is higher when you are pregnant.
However, if you produce too much prolactin prior to pregnancy, it has been shown to increase your chances for menstrual and ovulation problems that can lead to infertility. High prolactin levels can interfere with the normal production of other hormones such as estrogen and progesterone causing these reproductive challenges. (1)
Low and High Follicle-Stimulating Hormone (FSH) for Reproduction
FSH, a gonadotropin hormone is made in the pituitary gland and stimulates the growth and reproduction activities of the body
Low FSH is found in women who are advancing in age and is an indicator of secondary ovarian decline. In the normal aging process your number and quality of eggs that mature in your ovaries diminishes.
You will be tested at Inovi for this hormone to determine if you might have high or low levels of FSH. If your FSH is high, this may indicate an early onset of low or diminished ovarian reserve that leads to a reduction of follicles and eggs in your reproductive system. It can also lead to poor quality of eggs that make it much more difficult for a normal pregnancy.
Options for Pregnancy with High FSH
At Inovi we offer women hope for pregnancy with advancements in treatment for high FSH and diminished ovarian reserve. With assisted reproductive techniques and in vitro fertilization, your chances are improved.
Where Are Hormones Produced?
Your body’s hormones are produced in a region of your brain called the hypothalamous as well as in these glands and other organs such as:
- Pituitary Gland
- Adrenal Glands
- Thyroid Gland
What Hormones Are Tested For Infertility?
At Inovi we want to make certain you and your partner’s hormone levels are functioning correctly in order to move toward a successful pregnancy plan. We use blood tests to evaluate and check their status. These are among those hormones we monitor:
- Lutenizing Hormone (LH)
- Follicle-Stimulating Hormone (FSH)
- Prolactin (PRL)levels
- Anti-Mullerian Hormone (AMH)
In Vitro Fertilization
Diminished Ovarian Reserve
https://www.reproductivefacts.org › fact-sheets-and-info-booklets › hype…
Hyperprolactinemia (High Prolactin Levels) – ReproductiveFacts.org
2. J Reprod Infertil. 2009 Oct-Dec; 10(3): 207–212.
Hashimoto’s Disease: How It Could Affect Your Pregnancy
Hashimoto’s disease, sometimes referred to as Hashimoto’s thyroiditis, is an autoimmune disorder that affects the thyroid gland. Autoimmune conditions are the result of your immune system producing antibodies that attack your own tissues. Hashimoto’s disease means white blood cells have attacked the thyroid enough to slow it down, and it can lead to infertility or complications during pregnancy if left untreated.
Hashimoto’s Disease vs. hypothyroidism
Hashimoto’s is a disease, while hypothyroidism is a thyroid condition that can develop because of it. Not everyone with Hashimoto’s disease will develop hypothyroidism, but it is the most common cause. If you have an underactive thyroid, or too little thyroid hormone in your blood due to an issue like Hashimoto’s, the body is unable to function normally. Symptoms of hypothyroidism often include fatigue, weight gain, dry skin, mood swings and irregular periods causing infertility.
Can I get pregnant with Hashimoto’s disease?
Yes, but since Hashimoto’s disease is linked to infertility it can make getting pregnant more difficult. That’s because decreased levels of thyroid hormone interfere with ovulation. If a woman is anovulatory, or not ovulating, there is no egg released for fertilization by sperm. Without fertilization, pregnancy cannot occur.
How does your thyroid affect your pregnancy?
Women can develop hypothyroidism during pregnancy. If untreated, it can increase the chance of miscarriage, premature delivery and preeclampsia, which is a dangerous rise in blood pressure during the third trimester. There is also a higher risk of birth defects, intellectual and developmental issues for babies born to women with thyroid disease.
Is pregnancy safe with hypothyroidism? If treated, yes. The problem is that while it’s not especially difficult to treat, it often goes undiagnosed. Many symptoms of hypothyroidism and Hashimoto’s mimic first trimester complaints like fatigue, so a woman may not even know she has it until later in the pregnancy. Experts say that someone with a high risk, past history or symptoms of Hashimoto’s or other autoimmune diseases should have thyroid-stimulating hormone, or TSH, and thyroid blood tests done prior to conception, and thyroid function during pregnancy should be checked every 6-8 weeks. Hashimoto’s after pregnancy can still be an issue, but TSH levels often adjust by the third trimester.
Hashimoto’s pregnancy diet
While treatment of Hashimoto’s disease and hypothyroidism typically includes medication or Levothyroxine sodium pills, many find that prioritizing certain nutrients in their diet also help them to manage the condition.
Iodine is a mineral that is vital to the production of thyroid hormone and can be found in table salt, seafood and eggs.
Selenium has been shown to decrease the number of antibodies attacking the thyroid and can be found in eggs, chicken, beef, pork, and Brazil nuts.
Zinc is another essential element in producing thyroid hormone. It can be found in lentils and beans, shellfish, beef, and chicken.
A Paleo-inspired diet, which eliminates inflammatory grains, dairy and processed foods that can trigger an autoimmune reaction, is safe during pregnancy and can help keep Hashimoto’s in check.
Can Hashimoto’s cause miscarriage?
When the thyroid is functioning at a lower than normal level, it will impact other functions of the body; pregnancy is no exception. Evidence is still inconclusive regarding first trimester miscarriages, though a Chinese study in 2014 found that women with “both subclinical hypothyroidism and thyroid autoimmunity have a greater risk of miscarriage between weeks 4 and 8.”
There is greater evidence suggesting second-trimester miscarriages are more common. A 2000 study found that “women with untreated thyroid deficiency had a significantly increased risk of second-trimester miscarriage or stillbirth.” In 2005, a study found that “subclinical hypothyroidism could mean an increased risk of placental abruption and preterm delivery, both of which can result in later pregnancy loss.” Clearly, Hashimoto’s and hypothyroidism are conditions that should be addressed and treated as quickly as possible during pregnancy, if not before, to reduce the risk of miscarriage.
Assisted reproduction as an alternative
Because issues with thyroid hormones often lead to trouble conceiving, many women turn to assisted reproduction as an alternative. A 2016 study found that “having autoimmune thyroid disease did not seem to negatively impact the success of the fertility procedure itself and there were no differences identified in number of eggs retrieved, fertilization rates, implantation rates or confirmed pregnancy rates.” There was, however, a higher miscarriage rate and lower live birth rate. For women with severe thyroid issues who have struggled to maintain a healthy pregnancy, gestational surrogacy can be a viable option.
If you’d like to learn more about building your family through surrogacy, contact our team. We are here to answer your questions and help determine your best course of action.
90,000 Endocrine infertility treatment. Reflexology
There are 2 approaches to the treatment of endocrine infertility: outdated and modern
There are two approaches to the treatment of endocrine infertility. The most common – hormone therapy in combination with artificial insemination.
The second approach available in modern medicine is endocrine system restoration . How not to harm your unborn child while treating infertility? Which method of conception to choose?
Hormone therapy in combination with artificial insemination .It is necessary to take synthetic drugs, hormonal drugs that block and replace the missing hormones of their own with synthetic ones. Then, as a rule, artificial insemination is required. The main problem with such treatment is that the causes of infertility – immune and endocrine disorders – are not eliminated. At the same time, due to the intake of synthetic hormones, there are many side effects that can harm the expectant mother and her baby.
Endocrine system restoration .At the same time, the malfunction of the immune system and endocrine disorders are eliminated. Your own hormones begin to be produced in the amount the body needs and at the right time. Reproductive function is restored. The use of drugs and artificial insemination is not required. Fertilization occurs as a result of natural sexual contact. Pregnancy proceeds without complications and ends with a healthy birth. After childbirth, the body of a young mother quickly recovers.Treatment is carried out by the method of computerized reflexology.
The clinic uses only a restorative approach to the treatment of endocrine infertility. Our patients become parents in a natural way and without consequences for the health of their child .
Restoration of the endocrine system by computer reflex therapy
Treatment is based on the dynamic restoration of neuro-immuno-endocrine regulation of the woman’s reproductive system and subsequent restoration of the structure and function of organs involved in her reproductive function.
The fact is that the coordinated work of the internal organs of our body is regulated by the coordinated interaction of 3 main control systems: nervous , immune and endocrine . It is from their synchronous and well-coordinated work that the physical condition and health of a person depends. Any disease progresses and the body cannot cope with it on its own precisely because of the failure in the synchronous operation of these systems .
Rebooting the three main regulatory systems of the body to the state of active struggle against harmful external environmental influences and internal diseases is the main task of therapy focused on influencing the body through the autonomic nervous system.
There are many methods of influencing the nervous system, but, today, only computer reflex therapy acts through the nervous system so that in 93% cases, patients completely restore neuro-immuno-endocrine regulation of the body and, how as a result, many endocrine and neurological diseases that previously did not respond to drug “treatment” recede and completely disappear.
The effectiveness of therapy also lies in the fact that the doctor does not act on the patient’s body “blindly”, but, thanks to special sensors and a computer system, sees in which points of the nervous system and how many a medical device needs to be influenced …
Leave your contact and the consulting doctor will contact you
Samsonova Alsu Marsovna
Head of the department, endocrinologist, reflexologist, candidate of medical sciences.
Before each procedure, the doctor diagnoses the patient, based on the results of which he draws up an individual recipe for points for the procedure in accordance with the treatment plan. During the procedure itself, every second scanning of the current state of the patient allows you to accurately dose the effect, which, in principle, is absent when using any other methods.
Of course, this method of treatment, like any other, has restrictions and contraindications – these are oncological diseases and mental disorders , heart disorders ( pacemaker , atrial fibrillation and myacardial infarction in the acute period), HIV infection and congenital hypothyroidism. If you do not have the above contraindications, then endocrine infertility, safe for mother and child, without hormones and operations using this method has been a common practice in our clinic for many years.
For a good 20 years, the Gavrilova Clinic in the city of Samara has been carrying out restorative treatment of endocrine infertility without hormones and artificial insemination. The author and developer of the method is Natalia Alekseevna Gavrilova. Associate Professor, Ph.D. with general medical experience since 1968, awarded the Order of Medical Merit. If you wish, you can familiarize yourself in more detail with bioelectrophysical basics of the therapeutic effect of reflex therapy and specific examples of treatment .
Using the method of computer reflex therapy, the doctor restores the neuro-immuno-endocrine regulation of the patient’s entire body . Restoring the structure and function of the patient’s reproductive system is a manifestation of how the body, using its internal reserves and capabilities, restores itself in a natural way.
Treatment of endocrine infertility by computer reflex therapy without side effects leads to the following results:
- The functions of the immune system and segmental innervation of the pelvic organs are restored;
- Eliminates imbalance in the endocrine system;
- The production of own hormones is normalized without prescribing hormonal drugs, which is controlled by the results of laboratory tests during treatment;
- The structure and function of the ovaries is restored;
- The structure and function of the thyroid gland is restored;
- Often, after a course of treatment, diseases associated with the work of the nervous system, allergic and other autoimmune diseases disappear;
- Many patients report improvements in the condition of their skin and hair.This is how natural facial rejuvenation programs appeared in the clinic;
- And most importantly – you can naturally conceive and give birth to a healthy baby!
Leave your contact and the consulting doctor will contact you
Samsonova Alsu Marsovna
Head of the department, endocrinologist, reflexologist, candidate of medical sciences.
The information on the site is not intended for self-diagnosis and self-medication. If unwell, do not run the disease, seek qualified medical help.
- To come for treatment to the Gavrilova Clinic from another city, do not waste time thinking how to organize all this, call 8-800-55-00-128 from Russia for free, to call from other countries dial +7 846 374-07 -08 or +7 927 725 -11-44 (WhatsApp, Viber, Telegram). The consultant’s assistant will promptly answer your questions and help you organize your trip as comfortably as possible.
- To make an appointment with a doctor, contact the reception by phone +7 (846) 374-07-08, or via.
Click “Read more” to see examples of recovery
Pregnancy and hypothyroidism – MAMA Medical Center
Hypothyroidism is a condition in which the production of hormones by the thyroid gland is reduced. Most often, pregnancy with this disease simply does not occur, due to the fact that with a reduced thyroid function, ovulation does not occur. A condition known as primary anovulatory infertility occurs.If pregnancy does occur, and medications are not taken, then the normal development of the fetus is at risk.
Research shows that until the 16th week of pregnancy, the endocrine system of the fetus is not yet fully formed and is not able to function independently, therefore it develops under the influence of the mother’s hormones. If at the same time the mother’s need for thyroid hormones is not replenished, then irreversible changes in development and a decrease in intelligence may begin in the fetus.
Examination of the thyroid gland is included in the mandatory list of activities before starting planning. Even if no problems with the endocrine system were previously observed, it is worth taking tests of all the main hormones and performing an ultrasound of the thyroid gland. This will allow the endocrinologist to exclude many risks associated with both pregnancy and bearing a child. At the Mama MC we have repeatedly diagnosed hypothyroidism before and during pregnancy.
Numerous studies of this problem show that children whose mothers suffered from hypothyroidism during pregnancy and did not receive proper treatment are born with poor intelligence, survival and low Apgar scores.
At the same time, children whose mothers were on substitution therapy during pregnancy usually do not have such problems. This explains the urgent recommendations of doctors to be examined by an endocrinologist before planning a pregnancy.
If during the examination hypothyroidism was detected, then do not despair! The dosage of thyroxine correctly selected by a specialist and the intake of vitamins will be able to quickly stabilize the hormonal background of the body.
After consultation with an endocrinologist, it is necessary to monitor the level of free T4 and TSH in the blood every 1-2 months of pregnancy. With adequate and regular replacement therapy, there will be no complications during pregnancy. And a neglected disease can be transmitted to a child. Congenital hypothyroidism in children will have to be treated for your baby if you did not take care of your health during pregnancy.
Thus, hypothyroidism is a dangerous disease for both the expectant mother and her child.Therefore, it is necessary to consult an experienced endocrinologist when planning a pregnancy and when carrying a baby.
Doctor of the MC “Mama”, doctor of the highest category, chief freelance expert-endocrinologist of the Department of Health of the Kirov Region
Vedenskaya Tatiana Prokopyevna.
The thyroid gland is one of the endocrine glands that produces three hormones: thyroxine (T 4 ), triiodothyronine (T 3 ) and calcitonin.The first two regulate the metabolism of fats, proteins and carbohydrates, the function of the cardiovascular system, the gastrointestinal tract, mental and sexual activity, and calcitonin is one of the factors controlling calcium metabolism in cells and is involved in the growth and development of the bone apparatus.
The level of secretion of thyroid hormones is directly related to the activity of other endocrine glands: the pituitary gland, hypothalamus, as well as the adrenal glands and gonads.In addition, the presence of a sufficient amount of iodine in food has a significant effect on the work of the gland. Both excessive and insufficient functional activity of the thyroid gland is the cause of various diseases. Dysfunctions of the thyroid gland can have a plus sign – when hormones are produced in excess of the norm, and a minus sign when there are not enough hormones.
A condition when too much hormones are produced is called hyperthyroidism. Excessive production of hormones can cause such disturbances in the functioning of internal organs that sometimes it is in the nature of intoxication, and then hyperthyroidism is called thyrotoxicosis.
Symptoms of hyperthyroidism:
- general weakness, increased irritability and insomnia,
- tremors (tremors) of the hands,
- weight loss (with normal appetite),
- increased sweating and poor heat tolerance,
- heart palpitations, rhythm disturbances and high blood pressure,
- stool disorders (diarrhea),
- optional, but possible: double vision, exophthalmos (bulging).
What can hyperthyroidism cause?
The most dangerous conditions are atrial fibrillation and thyrotoxic crisis, requiring emergency hospitalization.In addition, hyperthyroidism causes rapid breakdown of muscle proteins and bone loss (osteoporosis). Degenerative changes in the heart develop, leading to chronic heart failure. The synthetic, detoxification and other functions of the liver decrease, the metabolism is sharply disturbed – carbohydrates, proteins, cholesterol, vitamins and minerals, and immunodeficiency occurs. There are also significant changes in the mental sphere. Neurotic disorders and depression progress.Decreased mood and performance. In women, the menstrual cycle is disturbed up to the cessation of ovulation and infertility. Men develop impotence and female breast degeneration (gynecomastia).
A condition when the thyroid gland gives less hormones than it needs is called hypothyroidism, which is sometimes not quite correctly called myxedema.
Symptoms of hypothyroidism:
- decreased mood and physical activity,
- weakness, drowsiness and chilliness,
- impaired concentration and slow thinking,
- wet and pale skin, edema,
- increase in body weight (even with decreased appetite),
- rare and weak pulse,
- Stool disorders (constipation).
Hypothyroidism is no less dangerous for the body than thyrotoxicosis. If untreated, deadly complications can develop – hypothyroid coma, accumulation of fluid in the pericardial sac and / or pleural cavity. Hypothyroidism, if left untreated, is serious, affecting the central nervous and cardiovascular systems in the first place.
If hypothyroidism develops in childhood, a disturbance in the activity of the central nervous system can manifest itself in an extremely serious form: the formation of dementia up to cretinism.In addition, the child does not grow, his sexual functions remain undeveloped. Self-reliant stool is usually difficult or even impossible. Such children are haunted by frequent infectious diseases with a long course.
If a pregnant woman suffers from hypothyroidism, then the child is also born with hypothyroidism and, quite often, with numerous developmental anomalies in the form of heart defects, abnormal development of internal organs, etc.
Untreated long-term hypothyroidism in an adult leads to serious disorders of thinking processes, memory, a decrease in initiative and performance to critical conditions.Apathy and depressive states develop. As a rule, the metabolism is seriously affected: the content of cholesterol in the blood rises significantly, which contributes to the early development of coronary heart disease and, as a result, myocardial infarction, as well as cerebral atherosclerosis with an outcome in stroke.
The production of digestive enzymes is sharply suppressed. A do-it-yourself chair is a rare feast. In hypothyroidism, as in thyrotoxicosis, profound disorders of the immune system occur, leading to frequent infectious diseases, the progression of autoimmune diseases and oncological pathology.
In women, in most cases, the menstrual cycle is disrupted – up to complete cessation. Ovulation is absent and, as a result, infertility is formed. Men with hypothyroidism also become infertile, their potency is sharply impaired.
Finishing a brief overview of the impaired functions of the thyroid gland, I would like to ask the question once again: is it necessary to be treated? The answer is obvious: sure, and the faster the better. Any dysfunction of the thyroid gland can be eliminated by the specialists of our Clinic – quickly enough, confidently and reliably, with the involvement of all methods known to modern medicine.
90,000 Subclinical hypothyroidism and pregnancy | Shestakova T.P.
This review presents the latest data on the impact of subclinical hypothyroidism on the course of pregnancy and its outcomes.
The special attitude to subclinical hypothyroidism is explained by the fact that so far no unambiguous tactics have been developed in relation to this disease, especially when it is detected during planning or after the onset of pregnancy.Many questions are either not studied, or have conflicting data, so the doctor makes a decision based on his ideas about this disease. Recently, the data of numerous studies, meta-analyzes devoted to this topic have been published. In this regard, it seems relevant to consider some issues related to subclinical hypothyroidism and pregnancy, which are primarily of interest to a practitioner.
The key issues are, first, the criteria for the diagnosis of subclinical hypothyroidism during pregnancy, which are inextricably linked with the concept of thyroid-stimulating hormone (TSH) norm for pregnant women; secondly, the effect of subclinical hypothyroidism on a woman’s fertility, the course and outcomes of pregnancy.
Norms of TSH during pregnancy
First of all, we will discuss the concept of TSH norms for pregnant women. Differences from the general population are due to physiological changes in thyroid function during pregnancy.
Penetration of thyroid hormones through the placenta to the fetus, an increase in the concentration of thyroid-binding
globulin, accompanied by increased binding of hormones, and their increased breakdown in the placenta under the influence of type 3 deiodinase dictate an increase in the synthesis of thyroid hormones in the woman’s body.For enhanced synthesis of hormones, it is necessary that the thyroid gland has sufficient functional reserves and there is no iodine deficiency. An additional stimulus for increasing the functional activity of the thyroid gland in the first trimester of pregnancy is the placental hormone – human chorionic gonadotropin (hCG), a TSH agonist capable of interacting with its receptors. Around the 8th week, at the peak of hCG secretion, the synthesis of thyroid hormones increases, which, through a negative feedback mechanism, suppress the production of TSH, so that for the first trimester, a decrease in TSH is typical, sometimes below normal.At the end of the first trimester, as hCG decreases, the TSH level is restored to its original values .
Studies have shown that the level of TSH and free T 4 90 180, but not free T 3 90 180, statistically significantly changes at different stages of pregnancy, with the minimum level of TSH observed at the beginning of pregnancy, and the minimum level of free T 4 90 180 – at the end of pregnancy .
Normal levels of thyroid hormones are important for both a pregnant woman and the fetus, especially in the first trimester, when the fetus’s own thyroid gland is not yet functioning.Taking into account the physiological changes in the function of the thyroid gland during pregnancy and the importance of maintaining a normal level of thyroid hormones for the correct formation and growth of the fetus, it is necessary to clearly define the concept of the norm for a pregnant woman, and this rate must be maintained throughout pregnancy. In addition, it is necessary to assess the justification of medical interventions during pregnancy, taking into account not only the health of the woman, but also the health of her unborn child.
Since 2011in our country, as in many other countries, trimester-specific TSH norms recommended by the American Thyroid Association (ATA) were used: for the first trimester 0.1-2.5 mU / l, for the second trimester – 0.2-3.0 mU / l and for the third trimester – 0.3-3.0 mU / l. It should be noted that in the ATA recommendations, these standards were proposed only for laboratories that, for some reason, do not have their own established standards. The recommended reference intervals for TSH were based on the results of six cohort studies conducted in the United States and some European countries, which showed that in the first trimester the level of TSH in pregnant women is significantly lower than in the second and third trimesters .
However, the use of such a rate has led to a very high prevalence of subclinical hypothyroidism in many countries. So, when using as the upper limit of the TSH norm for the first trimester of 2.5 mU / L in one study conducted in China, subclinical hypothyroidism was detected in 27.8% of pregnant women, in some regions of Spain in 37%, and in the Czech Republic in 21 % [4–6].
In this regard, in many countries in Asia and Europe, studies have been carried out to determine their own TSH norms.When summarizing the data of these studies, it was shown that the level of TSH in pregnant women without thyroid pathology living in different regions is significantly different. In the first trimester, the upper limit of normal TSH values is in the range from 2.15 to 4.68 mU / l. When using regional TSH norms, the incidence of hypothyroidism was significantly reduced and averaged about 4% [7, 8].
It should be noted that higher than 2.5–3.0 mU / l, the upper limit of the TSH norm was detected not only in Asian countries, such as India, South Korea, China [4, 9], but also in some countries Europe, for example the Netherlands, Czech Republic, Spain [10–12].These differences can be explained by ethnic characteristics, as well as the provision of iodine in the region in which the study is conducted, and the prevalence of carriage of antithyroid antibodies .
Taking into account the accumulated data, the ATA recommendations were issued in 2017 with some changes. It is still preferable to use the TSH rate for pregnant women, determined in this population, taking into account the place of residence. But if such norms cannot be determined for some reason, then it is recommended to use the reference values usually used in this population .However, in this case, physiological changes in TSH are not taken into account, especially in the first trimester of pregnancy. In a study conducted in the Netherlands, it was shown that when using the general population norms of TSH, it is impossible to detect in time all pregnant women with reduced thyroid function, which affects pregnancy outcomes . In this regard, it is advisable to reduce the commonly used upper limit of the TSH norm by 0.5 mU / l, which is also taken into account in the latest ATA recommendation .
Thus, taking into account the accumulated data and the latest recommendations of the ATA, it is currently recommended to use either the norms for pregnant women, determined in this ethnic group, taking into account the region of residence, or the commonly used population norms with a reduced upper limit by 0.5 mU / L.
Unfortunately, there are currently no national clinical guidelines in Russia for the diagnosis and treatment of thyroid diseases during pregnancy. In such a situation, each doctor relies on the information resources available to him. On the Internet resource Tironet.ru, well-known in Russia and very popular among doctors, in clinical guidelines based on the previous version of ATA recommendations, the TSH level is
Influence of subclinical hypothyroidism on fertility, course and outcomes of pregnancy
To determine the indications for the treatment of subclinical hypothyroidism, it is necessary to consider the effect of different TSH levels on the course of pregnancy and its outcomes.Unfortunately, not all studies identify groups of pregnant women with varying degrees of TSH elevation and take into account the titer of antithyroid antibodies, which also affect the course of pregnancy. In a study by N. Benhadi , a positive correlation was found between the TSH level, starting from normal values, and spontaneous abortion: with each doubling of TSH, the probability of miscarriage increased by 80%. An increase in TSH in the range of 2.5–5.0 mU / L in women without antithyroid antibodies is accompanied by an approximately 2-fold increase in the risk of miscarriage, both in early and late pregnancy [18, 19].
It should be noted that the effect of subclinical hypothyroidism on gestation increases with the use of local TSH norms. A study in Australia showed that the risk of miscarriage increases 3.66-fold with TSH> 95 percentile in early pregnancy, although TSH> 95 percentile combines subclinical and overt hypothyroidism, which may affect the results of the study .
The risks of spontaneous abortion increase with a combination of elevated TSH and high titer of antibodies to thyroid peroxidase (TPO).In a study by C. Lopez-Tinoco et al.  demonstrated that the presence of antibodies to TPO in pregnant women with subclinical hypothyroidism increases the risk of abortion by more than 10 times. Researchers from China received similar data. The highest risk of miscarriage was found in the group of pregnant women with subclinical hypothyroidism (TSH 5–10 mU / L) and an increased titer of antibodies to TPO (odds ratio (OR) 9.56; p2.5 mU / L and a high titer of antithyroid antibodies.
However, not all studies have confirmed the negative effect of TSH> 2.5 mU / L on the course of pregnancy.Thus, in the study by H. Liu  statistically significant differences in the frequency of abortion in the groups of pregnant women with TSH
A Cochrane review compared pregnancy outcomes for total thyroid dysfunction screening versus risk factor-based screening. With TSH> 2.5 mU / L, pregnant women underwent replacement therapy with levothyroxine. In the universal screening group, hypothyroidism was detected much more often (OR 3.15) and pharmacotherapy was prescribed more often, but, despite the better detection of hypothyroidism in the total screening group, there were no differences in pregnancy complications and its outcomes.The authors concluded that total screening does not improve pregnancy outcomes . However, the influence of weight cannot be excluded in this study, since healthy pregnant women significantly outnumbered patients with hypothyroidism in both groups.
Conflicting data were obtained when studying the association of subclinical hypothyroidism and preterm labor. In a study by Casey et al.  revealed a relationship between subclinical hypothyroidism and childbirth earlier than 34 weeks. gestation, but such a relationship was not found for periods of less than 32 or less than 36 weeks.Subsequently, in such studies, contradictory data were obtained, due in part to the unification of pregnant women with subclinical and overt hypothyroidism into one group, as well as the inclusion in the study of pregnant women with antithyroid antibodies.
As shown by T. Korevaar et al. , the complicated course of pregnancy depends on the degree of TSH increase. Pregnant women were divided into groups depending on the TSH level: 2.5-4.0 mU / L or more than 4.0 mU / L. With TSH below 4.0 mU / L, there was no increase in the incidence of preterm birth, while with TSH> 4.0 mU / L, the risk of childbirth earlier than 37 weeks.increased 1.9 times, and previously 34 weeks. – 2.5 times. But the primary analysis was carried out without taking into account the titer of antibodies to TPO. When pregnant women with elevated antibodies to TPO were excluded from the analysis, the difference between the groups disappeared, and even an isolated increase in TSH> 4 mU / L did not affect the rate of preterm birth. This study once again demonstrated the importance of distinguishing between pregnant women with normal and elevated antibodies to TPO, since they are an independent risk factor for complicated pregnancy.
The effect of subclinical hypothyroidism on the development of pregnancy-associated hypertension and preeclampsia is currently questionable. Previously, cohort studies have identified an association between subclinical hypothyroidism and preeclampsia, but only if screening for hypothyroidism was performed late in pregnancy. If the function of the thyroid gland was investigated up to 20 weeks. pregnancy, no dependence was found [26, 27]. It is assumed that at the initial stages of development of preeclampsia, the placenta can produce factors that affect the function of the thyroid gland .With an increased TSH (> 2.15 mU / l) in the first trimester of pregnancy, there was no increase in the frequency of pregnancy complications, including preeclampsia, developing after 20 weeks. .
When studying moderately elevated TSH, from 2.5 mU / L to 97.5 percentile, and the population norm, an increase in the incidence of preeclampsia was found only in pregnant women with high normal free T4, in the rest the high normal TSH level did not affect the frequency of preeclampsia . However, some studies still found an association between elevated TSH and high blood pressure during pregnancy.For example, the study by L. M. Chen  revealed an increased risk of gestational hypertension, as well as low fetal weight in pregnant women with subclinical hypothyroidism. That is, at first glance, diametrically opposite results were obtained. But in this study, subclinical hypothyroidism was diagnosed with TSH> 3.47 mU / L, which was defined as the upper limit of the norm in this laboratory, which is significantly higher than 2.5 mU / L. Probably, it is the TSH level used for the diagnosis of subclinical hypothyroidism that affects the results of the study of its effect on the course of pregnancy.
Usually, when there is conflicting data, a meta-analysis method is used to reveal the truth. A recent meta-analysis of 18 cohort studies showed that subclinical hypothyroidism is associated with several adverse pregnancy outcomes such as miscarriage (OR 2.01; 95% confidence interval (CI) 1.6–2.44), placental insufficiency (OR 2.14 ; 95% CI 1.23–3.7) and increased neonatal mortality (OR 2.58; 95% CI 1.41–4.73). There was no association with other adverse outcomes such as preeclampsia .It should be noted that the studies included in the meta-analysis used different TSH cut-off values for the diagnosis of subclinical hypothyroidism. Only in 6 out of 18 studies the TSH threshold was the level of 2.15–2.5 mU / L. Moreover, three studies included pregnant women with TSH ≥2.5 mU / L and a normal level of free T4. That is, the degree of TSH increase could be different, from 2.5 to 10 mU / l. And as we can see from other studies, different degrees of TSH elevation have different effects on pregnancy outcomes.In most meta-analysis studies, subclinical hypothyroidism was diagnosed with TSH> 3.5 mU / L. And this is just the upper limit of the TSH norm for pregnant women recommended today, if you use the modified general population norms.
The effect of TSH from 2.5 to 4 mU / L on the neuropsychiatric development of the fetus and other indicators of fetal health has not been identified [31, 32].
Considering the currently obtained data, it can be assumed that TSH> 2.5 mU / L is associated with spontaneous abortion.Other adverse pregnancy outcomes are associated with a higher TSH threshold. Pregnant women with elevated TSH and antithyroid antibodies deserve special attention. In this case, the adverse effect on the course of pregnancy increases.
But it is necessary to understand whether the situation will change for the better if the function of the thyroid gland is compensated for in subclinical hypothyroidism in pregnant women. Many researchers support the idea of treatment, because it is quite safe and can have a positive effect on pregnancy .Pregnancy outcomes did not differ in women taking levothyroxine sodium for overt or subclinical (TSH> 2.5 mU / L) hypothyroidism and in euthyroid women. And this indicates the safety of treatment with sodium levothyroxine, at least in relation to pregnancy .
The administration of levothyroxine sodium to pregnant women with TSH higher than the norm determined in the local laboratory led to an overall decrease in pregnancy complications. Moreover, the effect depended on the timing of the start of treatment and the time spent on reaching the target TSH level.
The complication rate decreased if treatment was started before 12 weeks. pregnancy and the goal of treatment was achieved in less than 4 weeks. .
In a study by S. Maraka et al.  showed that the appointment of substitution therapy with TSH 2.5–5 mU / L reduces the risk of intrauterine growth retardation and a low score for the state of the fetus at birth according to the Apgar scale. There were no differences in other pregnancy outcomes, including spontaneous abortion.
In other studies, the positive effect of treatment with levothyroxine was detected only in groups of pregnant women with TSH> 4.0–5.0 mU / L.At the same time, one study showed a significant decrease in the incidence of preterm birth (OR 0.38; 95% CI 0.15–0.98). In pregnant women with TSH 2.5–4.0 mU / L, the appointment of substitution therapy did not improve pregnancy outcomes [36–38].
Thus, at present, the positive effect of replacement therapy with sodium levothyroxine at a TSH level of 2.5–4.0 mU / L, especially at a normal level of antithyroid antibodies, has not been proven. At the same time, with a more pronounced increase in TSH, the positive effect of treatment is beyond doubt.It is possible that a positive effect is manifested only when using local TSH norms, which increases the importance of their determination.
Based on the latest data, it can be concluded that during pregnancy, it is better to use local TSH rates to decide on the appointment of treatment with levothyroxine sodium. In the absence of local norms, or with TSH> 2.5 mU / L in pregnant women with antithyroid antibodies, or TSH> 3.5 mU / L in women without antibodies, the appointment of substitution therapy at least reduces the likelihood of spontaneous abortion, and possibly has both other positive effects, especially if initiated early in pregnancy.
Subclinical hypothyroidism and fertility
An important question is what is the effect of subclinical hypothyroidism on a woman’s fertility. And this question gives rise to two more: 1) at what level of TSH is it necessary to start treatment when planning pregnancy
and 2) what is the target TSH level at the planning stage of pregnancy.
If a woman at the stage of pregnancy planning reveals TSH of a more general population norm, the appointment of treatment is beyond doubt.It is more difficult to resolve the issue of the need for treatment with a normally high TSH level. Recently, there is more and more data on the effect of moderately elevated TSH on fertility. Indeed, it was found that with infertility in a woman, the level of TSH is higher than in the control group, especially if the cause of infertility was ovarian dysfunction or the cause was unknown. . In one of the studies, administration of levothyroxine sodium to infertile women with TSH> 3 mU / L in 84.1% of women was accompanied by pregnancy, and in some women it was spontaneous .However, earlier studies have not found an association between elevated TSH and decreased fertility in women . The revealed single-time elevated TSH level> 2.5 mU / L at the stage of pregnancy planning can independently decrease after the onset of pregnancy. In one small study, it was shown that in 50% of pregnant women with TSH> 3 mU / L at the planning stage after pregnancy, the TSH level independently normalized and became less than 2.5 mU / L. Unfortunately, this study did not investigate the differences between groups with elevated and normal post-pregnancy TSH levels .
In a larger study of 482 women who underwent in vitro fertilization (IVF), the likelihood of occurrence was estimated at
and preservation of pregnancy depending on the initial TSH. In 55% of pregnant women, after the onset of pregnancy, TSH decreased from the initial level of 2.5–4.0 mU / L to 2.5 mU / L. The onset of pregnancy did not depend on the baseline TSH level. The authors concluded that treatment with an increase in TSH from 2.5 to 4.0 mU / L can be postponed until pregnancy, when this level will be confirmed .
On the other hand, in a population study conducted in China, a dependence of the outcomes of spontaneous pregnancy on the TSH level, determined within 6 months, was found. before pregnancy. In women with TSH 2.5–4.28 mU / l, when compared with women with TSH below 2.5 mU / l (0.48–2.49 mU / l), a slight but still statistically significant increase in the frequency of spontaneous miscarriages (OR 1.1) and premature birth
(OR 1.09). More severe complications of pregnancy, such as perinatal mortality, intrauterine fetal death, caesarean section, were observed only at TSH levels> 4.0 mU / L .
Many studies evaluate the impact of subclinical hypothyroidism and its treatment on the performance of various assisted reproductive technologies (ART). Special attention to this group of women is explained by the use of high doses of estrogens in the stimulation process, which can manifest compensated thyroid insufficiency. There was no negative influence of the TSH level from 2.5 to 4.9 mU / l on the results of insemination. One study in euthyroid women found an inverse association between TSH levels at the time of pregnancy and the frequency of spontaneous abortions .Another similar study did not find an association of an increased level of antithyroid antibodies and / or TSH> 2.5 mU / L on the birth rate in women after insemination , although in a retrospective study the effectiveness of insemination increased when substitution therapy was prescribed to women with a TSH level> 2 , 5 mU / l . IVF efficiency at a TSH level <2.5 mU / L was even higher and the quality of embryos was higher than in women with a higher TSH [48–50].
But not all studies have the same data.Thus, M. Aghahosseini et al.  found no statistically significant differences in the incidence of pregnancy as a result of ART, depending on the level of TSH. In a prospective study, it was shown that the appointment of substitution therapy in women with subclinical hypothyroidism (TSH 4.2–20.0 mU / L and free T4 is normal) before IVF improves its outcomes and they are comparable to euthyroid women. But we are talking about TSH levels above the population norm, but not about high-normal TSH.After the appointment of substitution therapy, differences in pregnancy outcomes depending on the target TSH level (0.5–2.5 or 2.5–4.0 mU / L) were not obtained, only its normalization was sufficient .
Thus, the appointment of substitution therapy at the stage of pregnancy planning, including for women planning ART, is indicated only when the TSH level rises above the general population norm. The use of standards for pregnant women at this stage is not justified.
An interesting question is also about the long-term risks of women with subclinical hypothyroidism identified during pregnancy.In a study conducted in India, it was shown that 2 years after pregnancy, 17.8% of women developed subclinical or overt hypothyroidism. The risk factors for the disease were age (23.6–25.5 years), goiter, the degree of TSH increase during pregnancy (7.9–5.1 mU / L), and an increased titer of antibodies to TPO . Thus, if such risk factors are present, periodic testing for hypothyroidism should be carried out, the frequency of the tests, however, has not been determined.
The data accumulated to date confirm the need to determine the local TSH rate for pregnant women.When deciding on the appointment of treatment during pregnancy, it is necessary to take into account not only the increased level of TSH, but also the level of antibodies to TPO, since it is in this group of pregnant women that there is the greatest risk of a complicated course of pregnancy. At the stage of pregnancy planning, treatment when TSH exceeds the general population reference values is mandatory. But the advantage of substitution therapy in women planning pregnancy, including with the help of reproductive technologies, with a high-normal level of TSH has not been proven.
“Menstrual irregularities” – St. Petersburg State Budgetary Healthcare Institution
“What is a violation of the menstrual cycle” This is a condition characterized by a change in the criteria characteristic of a normal menstrual cycle (duration, duration, abundance).
📌 Regular menstrual cycle = regular ovulation, in the vast majority of cases.That is why in case of violations of the cycle, you need to find out the reason for the lack of ovulation!
⏭ What causes can lead to a violation of the cycle?
✔ A very pleasant reason. The onset of pregnancy. If your period is late, take a pregnancy test.
✔ Thyroid disease – both hypothyroidism and hyperthyroidism, can be the reason for the lack of regular ovulation.
✔ Hyperprolactinemia – An increase in the level of monomeric prolactin can cause menstrual irregularities.
✔ The well-known PCOS is a syndrome of polycystic ovaries, in which the development of the follicle is inhibited to the dominant phase, which leads to the absence of ovulation.
✔ Congenital hyperplasia of the adrenal cortex, in which the level of androgens in the body increases, which can block folliculogenesis in the ovaries.
✔ Functional hypothalamic amenorrhea – a condition in which, against the background of chronic stress, eating disorders, heavy physical exertion, depression, the production of pituitary hormones decreases or the cyclicity of their synthesis is disrupted, which leads to a violation of ovulation.
✔ Lack of ovulation can be associated with other non-gynecological diseases – these can be autoimmune diseases, oncological diseases, brain injuries, its functional or organic pathology (tumors, cysts).
✔ Taking certain medications that can affect the female reproductive system.
🕵️♀️ Finding the cause of menstrual irregularities is a whole detective story! The main thing here is to have patience, time and faith in your doctor! 👩⚕️ Sometimes the reason lies on the surface, and sometimes you have to work hard to find out.
Ovarian Reserve and Autoimmune Thyroid Diseases | Grigoryan
Among endocrine disorders in women of reproductive age, thyroid pathology is the leading one. Subclinical hypothyroidism can lead to irregularity of the menstrual cycle, “chronic” anovulation syndrome, association of hypothyroidism with infertility, which indicates the effect of thyroid status on the growth and maturation of follicles .This observation has led to recommendations for the appointment of thyroxin preparations for women wishing to become pregnant with thyroid-stimulating hormone (TSH) levels of 2.5 μIU / ml and above . However, the results of clinical studies concerning this issue are contradictory. Thus, the study by Reh et al. showed no differences in the frequency of pregnancy and childbirth in in vitro fertilization (IVF) programs when the TSH threshold value was 2.5 or 4.5 μIU / ml , in another study the TSH level is less than 2.5 μIU / ml and the anti-Müllerian level hormone (AMH) more than 1.4 ng / ml were independent predictors of successful pregnancy with childbirth with unexplained infertility .A relationship was found between the presence of an autoimmune thyroid pathology and a decrease in fertility even with a normal TSH level [5, 6, 7], but the results are also contradictory.
The purpose of this review, carried out within the framework of the Russian Science Foundation grant No. 17-75-30035, is to systematize modern information on the effect of autoimmune thyroid pathology on the reproductive function of women. To understand the methodological approaches to the study of this problem, it is necessary to briefly dwell on the basic concepts of reproductive medicine.
Ovarian reserve is understood as the functional reserve of the ovary, which determines the ability of the latter to develop a healthy follicle with a full-fledged egg cell and an adequate response to ovarian stimulation. The ovarian reserve reflects the number of follicles in the ovaries (primordial pool and growing follicles) and depends on physiological and pathophysiological factors. The vast majority of ovarian reserve indicators characterize the hormone-dependent stage of follicular growth.These include the determination of basal levels of follicle-stimulating hormone (FSH), inhibin B, estradiol, luteinizing hormone (LH), as well as ultrasound determination of the number of antral follicles and ovarian volume . However, in recent years, as a result of a number of studies, it has been established that the most sensitive marker of ovarian reserve is the serum level of AMH produced by follicular granulosa cells from the preantral stages of maturation to the stage of large antral follicles [8, 9].Ovarian reserve, along with the patient’s age, the type of protocol for controlled ovarian hyperstimulation and the dose of gonadotropin, is one of the most important factors influencing the success of assisted reproductive technologies.
One of the first studies to assess the relationship between the presence of autoimmune antibodies and fertility was carried out by Wilson C. et al. in 1975 . The authors showed no relationship between the presence of anti-thyroid antibodies (ATA) and reproductive function.However, 20 years later, in a study by Roussev R.G. et al.  the detection rate of ATA in infertile patients was 8% versus 0% in the control group.
In 1997, Geva E. et al.  conducted a study that included 40 patients with idiopathic (unexplained) infertility, 40 patients with infertility due to obstruction of the fallopian tubes, and 40 healthy women who had not given birth before. The levels of ATA to the microsomal fraction of thyrocytes and to thyroglobulin (AT-TG) were assessed. The detection rate of ATA was 20% in the group of idiopathic infertility, 17.5% in the group with pathology of the fallopian tubes and only 5% in the group of healthy volunteers (p <0.05 when comparing this parameter between healthy women and both groups of infertile patients) ...
Subsequently, this correlation was confirmed: in one retrospective study, the detection rate of ATA in patients who entered ART programs was 19% versus 15% in the control group ; in another study, the detection rate of autoantibodies (including antibodies to thyroid peroxidase (AT- TPO) and AT-TG) was also higher in the group of patients with infertility. At the same time, in a 2001 study by Reimand K. et al.  showed no difference in the frequency of ATA detection in the group of women with infertility and in the control group.
Several studies have shown an association between the detection of ATA and specific causes of infertility. Thus, Poppee K. et al.  conducted a prospective study involving 438 women (mean age 32 ± 5 years) with infertility of various etiologies and 100 healthy women of comparable age. The aim of the study was to compare the prevalence of autoimmune diseases of the thyroid gland and latent disorders of its function. In 45% of cases, the main cause of infertility was the partner’s pathology, of which 11% – endometriosis, 30% – diseases of the fallopian tubes and 59% – ovarian dysfunction.The male factor occurred in 38% of cases, idiopathic infertility – in 17%. In general, the average TSH level was significantly higher in the group of women with infertility compared with healthy women (1.3 versus 1.2 mIU / L). The level of TSH exceeding normal limits was found equally often in the groups. AT-TPO was more often detected in women from infertile couples than in healthy couples (14% and 8%, respectively); however, the differences did not reach statistical significance. At the same time, in couples with a female factor of infertility, the carriage of ATA was detected much more often than in the control group: 18% versus 8%, while the highest percentage of women positive for AT-TPO was observed in patients with endometriosis with infertility.In the group of couples with infertility, an increase in the level of ATA was accompanied by a significantly higher frequency of detecting hypo- and hyperfunction of the thyroid gland compared with women from the same group, but with a normal level of AT-TPO. Thus, in this study, among women with infertility, the autoimmune pathology of the thyroid gland was significantly more common, and most of all this pattern was typical for patients with endometriosis. Similar results were obtained by Abalovich M. et al.  (the frequency of ATA detection in the group of infertile patients with endometriosis is 25% versus 14% in the group of healthy women).There are also reports of a higher frequency of ATA detection in infertile patients with polycystic ovary syndrome (PCOS) [7, 17] and premature ovarian failure .
Table 1 shows a comparison of the frequency of ATA positivity in infertile patients and healthy women.
Table 1. Comparison of the frequency of ATA positivity in infertile patients and healthy women.
ATA detection rate in infertility
The frequency of ATA detection in healthy women
Significance level of differences (p)
Geva et al.
20% (idiopathic infertility)
17.5% (tubal infertility)
Poppee et al. 
18% (with female factor of infertility)
Abalovich et al. 
25% (infertility + endometriosis)
Grassi G.et al.  studied the level of TSH, free thyroxine, as well as the levels of antibodies to microsomes and antibodies to thyroglobulin in 149 women with infertility. In case of deviation of any of the studied laboratory parameters from the norm, an ultrasound examination (ultrasound) of the thyroid gland was additionally performed and nonspecific autoimmune antibodies were determined. Despite the fact that the authors found a higher rate of detection of ATA in patients with infertility, the presence of such a laboratory phenomenon itself did not affect the likelihood of pregnancy.
Muller A.F. et al.  in a study involving 173 women who underwent IVF, the levels of AT-TPO and TSH were determined. An additional case-control study also measured anti-cardiolipin antibody levels. The aim of the study was to assess the frequency of miscarriages depending on the above parameters. Fifty-four out of 173 women became pregnant (31%), while the rate of pregnancy in ATA-positive patients was higher – 48% (12 out of 25) versus 28% (42 out of 148).In the group of AT-TPO positive patients, the frequency of miscarriages was 33% (4 out of 12), in the comparison group – 19% (8 out of 42), but the differences did not reach statistical significance. The presence of anticardiolipin antibodies in this study was also not associated with the incidence of miscarriages. The authors concluded that the presence of ATA before pregnancy, firstly, does not reduce the likelihood of pregnancy and, secondly, is not associated with an increased risk of miscarriages in IVF programs.
Kilic S. et al.  studied IVF outcomes, endometrial thickness and embryological parameters depending on ATA status in a study involving 69 women with idiopathic infertility.The study included women matched for age, body mass index (BMI), basal hormonal profile, and ovulation induction protocol. Depending on the results of testing for ATA, three groups were identified: negative (n = 31), positive (n = 23), positive in drug-induced euthyroidism (n = 15). There were no differences between the groups in the number of obtained and fertilized eggs, the thickness of the endometrium, the characteristics of the embryos. However, the incidence of clinical pregnancy was statistically significantly lower in the group of patients with AT-TPO (p = 0.024).Table 2 shows a comparison of the rate of successful pregnancy in infertile patients depending on the ATA status.
Table 2. The frequency of pregnancy in IVF programs in infertile patients, depending on the status according to ATA
Significance level of differences (p)
Muller et al.
Kilic et al. 
13.3% (in patients with medically compensated hypothyroidism)
30.4% (in patients with euthyroidism)
0.24 (when comparing groups negative for ATA and positive for ATA)
Despite the more than 40-year history of studying the connection between autoimmune thyroid diseases and fertility, interest in this problem has not diminished to this day.In recent years, several well-planned studies have been carried out, designed, taking into account the research methods available at this stage of the development of medical science, including the study of highly sensitive biomarkers, to establish the effect of ATA status on the ovarian reserve.
The aim of the study was V.A. Gurievoi et al.  was the establishment of the ovarian reserve in women at risk and the significance of the factors that determine it. The study included 174 women of reproductive age with impaired fertility, which made up the main group, the comparison group included 30 women with undisturbed reproduction.At the selection stage, women were randomized by age, social status, occupation, place of residence, somatic and gynecological pathology. The assessment of the state of the ovarian reserve in women of the compared groups was carried out by determining the level of sex hormones in the blood serum (FSH, LH, estradiol and AMH), and also assessed the ultrasound parameters of the ovarian reserve (ovarian volume and the number of antral follicles). ATAs were examined to determine the likely autoimmune damage to the ovaries.In 8.8% of women with impaired reproduction, an increase in ATA was revealed, the average values of which were 380 ± 111.4 IU / ml. 5.5% of women with reduced ovarian reserve were diagnosed with autoimmune thyroiditis, euthyroid, and in 30.8% of cases – hypothyroidism.
Pirgon O. et al. (2016)  studied ovarian function and ovarian reserve in girls with newly diagnosed chronic autoimmune thyroiditis (Hashimoto’s thyroiditis) in a state of euthyroidism. The case-control study included 30 girls (mean age 15.1 ± 1.4 g) with a high ATA titer and diffuse thyroid heterogeneity according to ultrasound data and 30 healthy age-matched girls.Parameters such as antiovarian antibodies (AOA), the ratio of LH to FSH (LH / FSH) levels, estradiol, AMH, inhibin-B, total testosterone levels, the number of antral follicles, ovarian volume, and uterine length were evaluated. There were no differences between the groups for parameters such as the LH / FSH ratio, estradiol and inhibin B levels. At the same time, the levels of AOA, AMG and testosterone were significantly higher in the group of patients with autoimmune thyroiditis (p = 0.02, p = 0.07 and p = 0.03, respectively). In girls with autoimmune thyroiditis, the AOA level positively correlated with the LH / FSH ratio (p = 0.03), AMH levels (p = 0.01) and inhibin B (p <0.001).The authors concluded that according to the results of all the tests performed, girls with chronic autoimmune thyroiditis retain a normal ovarian reserve. At the same time, an increase in the AOA titer associated with an increase in ATA requires caution regarding the possibility of developing premature ovarian failure in these girls, which is planned to be assessed in the long term.
Tuten A. et al.  also studied the effect of ATA status on ovarian reserve. The study included 22 women of reproductive age with Hashimoto’s autoimmune thyroiditis in the stage of hypothyroidism, who received thyroxine therapy, the control group consisted of 49 healthy women of comparable age.The authors showed that the ovarian reserve in patients with autoimmune thyroiditis was not only not reduced, but also exceeded that in healthy volunteers (significantly higher AMH level), while the number of antral follicles in women of the two groups was comparable. Nevertheless, the authors point out that ATA are associated with the development of PCOS, with the presence of which in the latent stage may be associated with an increase in the level of AMH.
Magri F. et al.  conducted a large study to investigate the relationship between ATA status and ovarian reserve.The study included 288 women under 40 years of age with reduced fertility in a state of euthyroidism. 55 of them were ATA positive. Prior to controlled ovarian hyperstimulation, serum levels of AMH, FSH, LH, estradiol, TSH were measured. The ratio between the serum estradiol concentration (E2) on the day of oocyte retrieval and the total administered dose of recombinant FSH (E2 / rFSH) was also calculated. Serum AMH levels significantly correlated with the value of the E2 / rFSH ratio, the total dose of rFSH administered, and the number of mature (M II) eggs, regardless of the ATA status.At low AMH values, the presence of ATA did not have an additional effect on the outcomes of controlled ovarian hyperstimulation; however, at high AMH values, the presence of ATA had a significant effect on the E2 / rFSH ratio, the total dose of rFSH, and the number of mature eggs. The authors concluded that with low AMH levels, there is a poor response to controlled ovarian hyperstimulation regardless of the presence of ATA, while with high AMH levels, indicating a good ovarian reserve, ATA worsen the outcomes of controlled ovarian hyperstimulation.
Large cross-sectional retrospective study by N.P. Polyzos et al.  is also devoted to the study of the question of whether autoimmune diseases of the thyroid gland lead to a decrease in ovarian reserve. Information from the cards of 4894 women was taken from the archives of the Center for Reproductive Medicine at the University Hospital of Brussels. The effect of AMH, free thyroxine, TSH, and AT-TPO levels on outcome was assessed. Judging by the level of AMH, 3929 patients had a normal ovarian reserve, decreased – in 487 and high – in 478.TSH and free thyroxine levels did not differ between groups with different ovarian reserves. The detection rate of AT-TPO among women with low, normal and high AMH levels also did not differ (12.1%, 10.3% and 9.8%, respectively, p = 0.423). Subclinical or latent hypothyroidism was also detected with the same frequency in different groups. Moreover, in patients with genetic causes of reduced ovarian reserve, the frequency of latent or subclinical hypothyroidism was significantly higher than in the group with an unexplained decrease (25% versus 3.2%, p = 0.002, and 18.8% versus 1.6%, p = 0.004).At the same time, hypothyroidism occurred equally often with a decrease in the ovarian reserve of various etiologies.
At the same time, Saglam F. et al.  came to the opposite result. The study included women of reproductive age (under 40 years old), 85 with the presence of ATA and 80 healthy volunteers. The reproductive history (the number of pregnancies, their outcomes) was studied in detail, and the levels of gonadotropins, steroids, AMG and inhibin B were measured in the follicular phase. The number of pregnancies and live births was less in the group of women with autoimmune thyroid diseases (p <0.01) ...There were no differences in FSH, estradiol or inhibin B levels. However, the AMH level turned out to be significantly lower in patients with ATA carriage as compared to the control (1.16 ± 0.17 versus 1.28 ± 0.25 ng / ml, p = 0.001). Even after adjusting for age, the presence of ATA significantly and independently determined a lower AMH level (multiple regression analysis, t = 2.674, p = 0.008). The authors concluded that, in all likelihood, autoimmune diseases of the thyroid gland predetermine the decrease in ovarian reserve. Ayesha et al. showed that autoimmune diseases of the thyroid gland are the most common autoimmune pathology in patients with premature ovarian failure.
Weghofer A. et al.  decided to find out what actually affects the ovarian reserve: a decreased function of the thyroid gland or its autoimmune pathology. The study included 225 women with infertility, mean age 38.4 ± 5 years. The interval from 0.4 to 4.5 μIU / ml was taken as the normal level of TSH, and the level of AMH was assessed depending on the level of TSH less than 3 or from 3 or more μIU / ml.The level of ATA was also determined: AT-TPO, AT-TG and antibodies to thyroid receptors. The average AMH level was 1.3 ± 2.0 ng / ml, the average TSH level was 1.8 ± 0.9 μU / ml. ATA was detected in 11.1% of patients. In women with TSH levels less than 3 μIU / ml, the AMH level was significantly higher than in patients with TSH ≥ 3 μIU / ml (p = 0.03). This difference persisted after adjusting for ATA status and age. According to the authors, their observation confirms the fact that the ovarian reserve depends on the function of the thyroid gland, and not on the carriage of ATA.In this regard, they believe that in order to increase the ovarian reserve, it may be advisable to prescribe thyroxine to patients with a TSH level ≥ 3 μIU / ml.
Thus, the literature data, regardless of the age of the studies and diagnostic capabilities, both for the detection of autoimmune thyroid pathology and for the determination of the ovarian reserve, are contradictory. At the same time, it is obvious that even the identification of a correlation between the carriage of ATA and a decrease in the parameters characterizing the ovarian reserve does not prove a causal relationship.The authors, claiming the existence of such a connection, offer various hypotheses for the pathogenesis of ovarian failure and the pathology of pregnancy in autoimmune diseases of the thyroid gland. One of the explanations is subclinical hypothyroidism or inability of the thyroid gland to adequately respond to the request arising from ovarian hyperstimulation or during pregnancy [29, 30].
An interesting hypothesis based on the results of their own research was put forward by Monteleone P. et al. .A prospective observational study included 31 patients with primary infertility due to male or tubal factor with a basal FSH level on the third day of less than 10 IU / L and a good response to controlled ovarian hyperstimulation (more than 3 follicles of at least 18 mm at the end of the stimulation cycle). The levels of ATA (AT-TG, AT-TPO) were determined, according to the results, the patients were divided into two groups: positive for ATA (n = 14) and negative for ATA (n = 17, control group). Other autoimmune diseases, PCOS, and endometriosis were used as exclusion criteria.When performing ART procedures on the day of oocyte retrieval by fine-needle aspiration, samples of follicular fluid were taken for analysis for the ATA level. It turned out that in patients positive for ATA, they are determined in the follicular fluid, and their level is approximately half of the level in the blood plasma. At the same time, the presence of ATA was associated with a decrease in the frequency of successful fertilization, obtaining class A embryos and the onset of pregnancy, as well as an increase in the frequency of early miscarriage.According to the authors, ATA can cause antibody-dependent cytotoxicity in the growing follicle, damage the maturing egg, reducing its potential for further development and subsequent implantation of the embryo.
There is further evidence that ATA can cross-react with ovarian cells, including eggs. So, Kelkar R.L. et al.  showed that ATA was detected in 5 out of 8 women with premature ovarian failure and the presence of antibodies to the transparent membrane of the egg ( zona pellucida ), while antibodies to the transparent membrane cross-reacted with antigens of the transparent membrane of eggs of other species (sheep, monkeys , pigs, mice), and from other tissues in mice they had an affinity only for the thyroid gland.Therefore, we can assume the affinity of ATA for oocytes.
Thus, the data on the effect of ATA carriage on the reproductive function of women are contradictory, and the expediency of including them in screening examinations in women receiving treatment within the framework of ART programs is controversial. At the moment, there is no unified approach to the interpretation of the results of such testing and evidence-based recommendations regarding changes in treatment tactics depending on the status of patients according to ATA.To answer these questions, it is necessary to conduct large, well-planned randomized controlled clinical trials that will reveal possible pathogenetic links between a decrease in ovarian reserve and the presence of autoimmune thyroid pathology, as well as formulate recommendations for personalized treatment of patients to improve reproductive health.
Funding source. This work was supported by a grant from the Russian Science Foundation “Autoimmune endocrinopathies with multiple organ lesions: genomic, postgenomic and metabolic markers.Genetic risk prediction, monitoring, early predictors, personalized correction and rehabilitation “(Grant of the Russian Science Foundation No. 17-75-30035).
Conflict of interest. The authors declare no obvious and potential conflicts of interest related to the publication of this article.
Contribution of authors. All authors made a significant contribution to the research and preparation of the article, read and approved the final version of the article before publication.
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19.Muller A, Verhoeff A, Mantel M, Berghout A. Thyroid autoimmunity and abortion: a prospective study in women undergoing in vitro fertilization. Fertil Steril. 1999; 71 (1): 30-34. doi: 10.1016 / S0015-0282 (98) 00394-X
20. Kilic S, Tasdemir N, Yilmaz N, et al. The effect of anti-thyroid antibodies on endometrial volume, embryo grade and IVF outcome. Gynecol Endocrinol. 2008; 24 (11): 649-655. doi: 10.1080 / 09513590802531112
21.Guryeva V.A., Kurakina V.A. Assessment of the factors determining the ovarian reserve in women with impaired reproductive function // Journal of Obstetrics and Women’s Diseases. – 2012. – T.61. – No. 6. – P.76-81. [Gur’eva VA, Kurakina VA. Evaluation factors, determining ovarian reserve in women with reproductive function disorders. Journal of obstetrics and women’s diseases. 2012; 61 (6): 76-81. (In Russ.)]
22. Pirgon O, Sivrice C, Demirtas H, Dundar B.Assessment of ovarian reserve in euthyroid adolescents with Hashimoto thyroiditis. Gynecol Endocrinol. 2016; 32 (4): 306-310. doi: 10.3109 / 09513590.2015.1116510
23 Tuten A, Hatipoglu E, Oncul M, et al. Evaluation of ovarian reserve in Hashimoto’s thyroiditis. Gynecol Endocrinol. 2014; 30 (10): 708-711. doi: 10.3109 / 09513590.2014.926324
24.Magri F, Schena L, Capelli V, et al. Anti-Mullerian hormone as a predictor of ovarian reserve in ART protocols: the hidden role of thyroid autoimmunity. Reprod Biol Endocrinol. 2015; 13 (1): 106. doi: 10.1186 / s12958-015-0103-3
25. Polyzos NP, Sakkas E, Vaiarelli A, et al. Thyroid autoimmunity, hypothyroidism and ovarian reserve: a cross-sectional study of 5000 women based on age-specific AMH values. Hum Reprod.2015; 30 (7): 1690-1696. doi: 10.1093 / humrep / dev089
26. Saglam F, Onal ED, Ersoy R, et al. Anti-Müllerian hormone as a marker of premature ovarian aging in autoimmune thyroid disease. Gynecol Endocrinol. 2015; 31 (2): 165-168. doi: 10.3109 / 09513590.2014.973391
27. Ayesha, Jha V, Goswami D. Premature Ovarian Failure: An Association with Autoimmune Diseases.J Clin Diagn Res. 2016; 10 (10): 10-12. doi: 10.7860 / JCDR / 2016 / 22027.8671
28. Weghofer A, Barad DH, Darmon S, et al. What affects functional ovarian reserve, thyroid function or thyroid autoimmunity? Reprod Biol Endocrinol. 2016; 14 (1): 26. doi: 10.1186 / s12958-016-0162-0
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32. Kelkar RL, Meherji PK, Kadam SS, et al. Circulating auto-antibodies against the zona pellucida and thyroid microsomal antigen in women with premature ovarian failure. J Reprod Immunol. 2005; 66 (1): 53-67.doi: 10.1016 / j.jri.2005.02.003
90,000 Postpartum contraception · Unilab Clinic
Pregnancy can occur even before the first menstrual period
A miracle happened. The baby, whose birth you have been waiting for for nine long months, was born. Now you are immersed in worries. At first, you get terribly tired, night feedings are exhausting. The doctor recommends not to have sexual intercourse for the first 4-6 weeks … Contraception is probably the last thing you think about now.Is it worth taking care of her at all?
Worth it if you want to avoid an unplanned pregnancy in the first months after giving birth. Contrary to popular belief, this is not uncommon. Studies have shown that in women who are breastfeeding, menstruation resumes on average after 2-6 months, depending on the intensity of feeding, and in non-lactating women – 4-6 weeks after giving birth.
If you are not lactating or breastfeeding irregularly, then ovulation, and, consequently, the ability to conceive, can resume as early as 25, and on average 45 days after birth.And since ovulation occurs 14 days before your period, you may already be fertile without knowing it.
Pregnancy can occur even before the onset of the first menstrual period, therefore, in order to begin to protect yourself, one should not expect a restoration of the menstrual cycle, the beginning of complementary feeding and a reduction in the frequency of breastfeeding.
High-risk group for unplanned pregnancy
According to surveys, 33% of Russian women resume sexual relations within a month after giving birth, and within 4-6 months – 98% of women.Doctors are alarmed by the fact that after childbirth, 20–40% of sexually active women do not use any methods of contraception. Meanwhile, the probability of pregnancy in the absence of reliable contraception in nursing mothers 6–8 months after childbirth reaches 10%, and in non-lactating women – 50–60%.
Thus, women who have recently given birth in Russia should be classified as a high-risk group for an unplanned pregnancy.
The onset of pregnancy during this period is highly undesirable.Doctors believe that the minimum interval between births should be about 3 years. Why? Despite the fact that the involution of the organs of the reproductive system (their return to their previous state) ends 4–6 weeks after childbirth, full recovery of the body takes at least 1.5–2 years. Breastfeeding is also a significant burden on a woman’s body.
But a woman after that still needs to replenish the supply of important trace elements, such as iron, calcium and others.Studies have shown that with the onset of pregnancy earlier than 2 years after childbirth, the risk of complications of pregnancy (gestosis, anemia, intrauterine growth retardation), childbirth and the postpartum period doubles.
Thus, we inevitably come to the conclusion that in the postpartum period and within 2 years after childbirth, a woman needs effective, reliable and safe contraception.
Choice of method of contraception after childbirth
It is important to get advice and choose a suitable method of contraception after childbirth should be still during pregnancy.Do not have time before the birth – consult the doctor of the maternity hospital. If, nevertheless, it was not possible to decide on the method of contraception, or you have doubts and questions, then before resuming sexual relations (even with breastfeeding), be sure to seek advice from a gynecologist, for example, an antenatal clinic or a family planning and reproduction center.
A non-lactating woman should start using contraceptives from the moment of the resumption of sexual relations. Moreover, if there are no special contraindications, she can choose any of the modern arsenal of contraceptives.
The breastfeeding method of contraception depends on the mode of feeding and the time elapsed after childbirth. In addition, the contraceptive should not adversely affect either the child’s health or milk secretion. For exclusive breastfeeding, initiation of contraceptive use can be delayed by up to 6 months. With infrequent feeding or early initiation of complementary feeding (all this is typical for residents of developed countries), the method of contraception should be selected during a mandatory postpartum visit to the doctor no later than 6 weeks after birth.
Important note: different methods have different effectiveness, some involve serious restrictions in use, not all can be used in the first weeks after childbirth. Different methods of contraception will often have to be combined. Either by increasing the effectiveness of a tool that is ideal for you, but not sufficiently reliable, or by “taking care” in those circumstances when the effectiveness of a reliable method for some reason decreases. Only a doctor will help in determining the need and principles for combining various methods, as well as in choosing the most suitable remedy for your pair.
Withdrawal – 100% contraceptive effectiveness
Abstinence (abstinence) has 100% contraceptive effectiveness, but most couples are not satisfied with this method even for a short time.
About other methods of contraception after childbirth, about the advantages and disadvantages, in our next publications. And more detailed information and suitable methods of contraception just for you will be advised by a gynecologist.
Method of lactational amenorrhea – efficiency 98%.
After childbirth, the body produces the hormone prolactin, which stimulates milk production by the mammary glands and at the same time suppresses ovulation, resulting in lactational amenorrhea (absence of menstruation during breastfeeding). This effect of prolactin on the woman’s body determines the contraceptive effect of breastfeeding.
Each act of breastfeeding by the baby stimulates the secretion of prolactin, but if the break between feedings is too long (more than 3-4 hours), the prolactin level gradually decreases.Breastfeeding, started immediately after childbirth, is an effective method of natural contraception and at the same time provides the baby with the most complete nutrition. In addition, sucking stimulates the production of oxytocin, a hormone that contributes not only to the contraction of the muscles of the areola of the mammary gland (due to which milk is released from the nipples), but also to the contraction of the uterus, which leads to the early restoration of its size and shape after childbirth.
MLA assumes exclusive or almost exclusive breastfeeding, both day and night.The effectiveness of MLA is maximum if feeding does not take place according to the schedule, but at the first request of the child (even at night), sometimes several times per hour, on average 12 to 20 times a day, of which 2–4 times at night. The break between feedings should not exceed 4 hours during the day and 6 at night. In this case, each time it is necessary to give the baby the breast, and not express milk. The contraceptive effectiveness of MLA remains at an acceptable level if the proportion of complementary foods is no more than 15%.
Terms of application. The first 6 months after giving birth with proper breastfeeding.Efficiency: 98%.
- Easy to use.
- Gives a contraceptive effect immediately from the start of use.
- Does not affect intercourse.
- Promotes uterine contraction, reducing the risk of postpartum complications (bleeding) and leading to an early recovery of the body.
- Does not require medical supervision.
- Good for the baby (breastfeeding provides him with the most adequate nutrition, promotes the development of immunity, reduces the risk of infection).
- Requires strict adherence to the above rules for breastfeeding.
- Not acceptable for working women.
- Short-term in use (6 months).
- Does not protect against sexually transmitted diseases.
Oral contraceptives – efficiency approaching 100%
Progestin-only oral contraceptives (“mini-pills”)
The tablets contain progestins – synthetic hormones, the effect of which is to reduce the amount and increase the viscosity of the cervical mucus (which prevents the passage of sperm into the uterus), changes the structure of the mucous membrane of the uterine body (this prevents embryo implantation) and suppresses ovulation.
Beginning of application. Women who are breastfeeding can start taking pills 5–6 weeks after giving birth, and those who are not breastfeeding can start taking pills from the 4th week after giving birth or at the onset of menstruation.
98% with correct and regular intake of tablets in combination with breastfeeding.
Advantages. Do not adversely affect the quantity, quality of milk and duration of lactation.
In the first 2-3 cycles of admission, intermenstrual spotting is often noted, which is a consequence of the adaptation of the body to the drug.Some women may experience menstrual irregularities up to amenorrhea.
Oral contraceptives are prescribed by a doctor. They must be taken daily, without interruption, strictly at the same time. Violation of the time of taking or skipping pills, as well as the simultaneous use of certain antibiotics, anticonvulsants and hypnotics, vomiting or diarrhea reduce the contraceptive effect. The ability to conceive is usually restored immediately after discontinuation of the drug.After stopping feeding, you should switch to combined OCs, which have a higher efficiency.