Thyroid Disorders and In Vitro Outcomes of Assisted Reproductive Technology: An Unfortunate Combination?

Background: The impact of thyroid disorders on in vitro outcomes of assisted reproductive technology (ART) remains controversial. Therefore, the aim of our study was to investigate whether thyroid peroxidase antibodies (TPO-Abs)/thyroid autoimmunity (TAI) or thyroid function (serum thyrotropin [TSH])/subclinical hypothyroidism are associated with an altered number of oocyte retrieval (NOR), fertilization rate (FR), and embryo quality (EQ). Methods: Cross-sectional study in 279 women in a single center, comprising 297 cycles and 1168 embryos. In vitro data (NOR, FR, and EQ) were documented in two groups; one according to thyroid function in women without TAI (TSH ≤2.5 and >2.5 mIU/L) and one according to the presence/absence of TAI (determined by TPO-Abs). EQ was evaluated according to international criteria and classified as excellent/good and poor. Women treated with levothyroxine (LT4) were excluded. Furthermore, the impact of thyroid parameters on outcomes, normal NOR (>6 or 8) and high FR (>60%), was verified in a multivariable logistic regression model. Results: In women without TAI, 27% had TSH levels >2.5 mIU/L, the prevalence of TAI was 8%, and overall, 6% of women had TSH levels >4.2 mIU/L. NOR, FR, and EQ were comparable between study groups. In the regression analysis, women aged ≥30 years and receiving a high ovarian stimulation dosage (>2300 IU/cycle) had lower rates of normal NOR (odds ratio [OR] 0.18 [95% confidence interval, CI 0.04-0.72]; p = 0.016 and OR 0.17 [CI 0.06-0.48]; p < 0.001, respectively). Conclusions: Our results do not suggest an impact of thyroid antibodies/autoimmunity and (dys)function on ART in vitro outcomes.

The efficacy of acupuncture for the treatment and the fertility improvement in child-bearing period female with Hashimoto Disease: A randomized controlled study

BACKGROUND

Hashimoto thyroiditis (HT) is highly prevalent among reproductive-aged women and has a substantial negative impact on fertility. Currently, there is no specific treatment for Hashimoto thyroiditis. We hypothesize that acupuncture can halt or delay the progression of HT and improve fertility in child-bearing period female. We therefore designed a randomized controlled trial to test this hypothesis by comparing the therapeutic effect of acupuncture vs sham acupuncture in patients with Hashimoto thyroiditis.

METHODS

In this randomized controlled study, a total of 284 eligible patients will be assigned to acupuncture group (n = 142) or sham acupuncture group (n = 142) in a 1:1 ratio. All patients will receive 36 sessions in total for 12 consecutive weeks with the same acupoint prescription (RN23, ST9, RN17, RN4, RN6, ST36, SP6, KI6). The primary assessment is the titers of thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibody (TGAb). Secondary outcomes include the thyroid function, ovarian function, the rate of primary ovarian insufficiency, and pregnancy outcome. The thyroid function and thyroid antibodies tests will be measured at weeks 0, 4, 8, and 12 after randomization. The ovarian function will be examined on the 2nd to 4th day of the menstrual period in the 1st month, 2nd month and 3rd month compared with baseline. Both the pregnancy outcome and the rate of primary ovarian insufficiency will be evaluated 1 year after treatment.

DISCUSSION

This will be the first large-scale trial specifically evaluating acupuncture therapy in child-bearing period female with Hashimoto thyroiditis. If the study confirms the effectiveness of acupuncture treatment, more consistent acupuncture therapy can be set up for clinical practice.

TRIAL REGISTRATION

Chinese Clinical Trials Register identifier, ChiCTR2000031320, registered on 27 March 2020.

Impact of thyroid disease on fertility and assisted conception

Thyroid autoimmunity (TAI) and/or thyroid dysfunction are prevalent in women of reproductive age and have independently been associated with adverse fertility and pregnancy outcomes, in the case of spontaneous conception or after assisted reproductive technology (ART). Thus, it seems reasonable to screen for thyrotropin (TSH) and thyroid peroxidase autoantibodies (TPO-abs) in infertile women attempting pregnancy. However, even if the relationship between fertility and thyroid dysfunction and/or TAI persists when properly controlled for other variables, it remains challenging to claim causation. Several studies with different designs (cross sectional, case -control, prospective and retrospective cohort studies) have looked at the association between thyroid autoimmunity, thyroid function and fertility. Heterogeneity among study results are related to small numbers of included patients, poor study design, selection of causes of infertility and different assays used to measure TAI, thyroid hormones and TSH reference values. Indeed, there is no consensus regarding the upper limit of normal for TSH to define thyroid dysfunction and the cut-off levels for intervention. Furthermore, data from interventional trials looking at the impact of levothyroxine treatment on fertility outcome in randomised controlled studies are scarce. Despite the recent update of the guidelines by the American Thyroid Association (ATA) for the Diagnosis and Management of Thyroid Disease during Pregnancy and the postpartum, many questions remain unsettled in ART.

Antinuclear antibodies in follicular fluid may reduce efficacy of in vitro fertilization and embryo transfer by invading endometrium and granular cells

PROBLEM

The mechanism(s) by which antinuclear antibodies (ANA) induce implantation failure are not clear, and little information regarding the function of autoantibodies in reproductive tissues is available.

METHODS OF STUDY

A total of 380 patients who underwent in vitro fertilization and embryo transfer (IVF-ET) were divided into control, serum positive, and follicular fluid (FF) positive groups based on the results of indirect immunofluorescence assay for ANA in the serum and FF. Immunofluorescence assay was performed to evaluate the existence of ANA in granular cells and endometrial tissues. Presence in FF of soluble apoptotic markers, including Bcl-2, Caspase-3, cleaved PARP, Cytochrome C, GAPDH, and p53, was assessed using magnetic bead based assays.

RESULTS

The patients in the FF positive group had the lowest numbers of retrieved oocytes, fertilizations, and high-quality embryos. The fertilization rate, and the proportion of two pronuclear (2PN) embryos in patients in the FF positive group were significantly lower than those in the other two groups. The FF positive group also had the lowest clinical pregnancy rate, and the highest early miscarriage rate. Granulosa cells and endometrial tissues in patients in the FF positive group were ANA positive. High levels of BCL-2, Caspase-3, Cytochrome C, GAPDH, and p53 were found in the FF of patients in the FF positive group.

CONCLUSIONS

Antinuclear antibodies in FF and endometrial tissues may cause imbalanced apoptosis, resulting in poor IVF-ET treatment outcomes. Local autoimmunity and cell apoptosis in reproductive tissues could be considered new therapeutic targets for improving IVF-ET treatment efficacy.

Protein Expression Profile in IVF Follicular Fluid and Pregnancy Outcome Analysis in Euthyroid Women with Thyroid Autoimmunity

The objective of this study is to investigate the influence of the thyroid autoantibodies on the protein expression in follicular fluid and the clinical outcome of assisted reproductive technology. A total of 602 patients treated for infertility were screened; 49 euthyroid women who were positive for thyroid autoantibodies and 63 negative controls were recruited. Follicular fluid samples were analyzed using proteomics. Validation of target proteins in follicular fluid was performed by using parallel reaction monitoring. Differentially expressed proteins in follicular fluid, clinical pregnancy rate, abortion rate, and live-birth rate were analyzed. Clinical pregnancy rates and take-home baby rates in the thyroid autoimmunity (TAI) group were less than in the control group, but abortion rates in the TAI group were higher than in the control group (all P < 0.005). A total of 49 proteins were differentially expressed in the TAI-positive group. In Gene Ontology secondary annotations of all the proteins identified, five types of proteins were associated with the reproductive process. Among 11 proteins quantitatively identified by parallel reaction monitoring, angiotensinogen and fetuin-B were associated with reproduction. These differentially expressed proteins identified in this study involved multiple pathways according to the Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis. Our study provides evidence that some differentially expressed proteins between TAI-positive women and controls were associated with the reproductive process and closely related to important physiologic effects, which could partially explain the underlying mechanism link between TAI and the adverse outcomes of assisted reproductive technology.

Effect of levothyroxine supplementation on pregnancy loss and preterm birth in women with subclinical hypothyroidism and thyroid autoimmunity: a systematic review and meta-analysis

BACKGROUND

Subclinical hypothyroidism (SCH) and thyroid autoimmunity (TAI) are associated with adverse pregnancy outcomes such as pregnancy loss and preterm birth. However, the ability of levothyroxine (LT4) supplementation to attenuate the risks of these outcomes remains controversial.

OBJECTIVE AND RATIONALE

This systematic review and meta-analysis was conducted to determine the effect of LT4 supplementation on pregnancy loss rate (PLR) and preterm birth rate (PBR) among pregnant women with SCH and TAI.

SEARCH METHODS

A systematic literature search of the PubMed, EMBASE, Web of Science and Cochrane Controlled Trials Register databases and Clinicaltrials.gov was performed to identify all relevant English studies published up to April 2018. The following terms were used for the search: [subclinical hypothyroidism OR thyroid autoimmunity OR thyroperoxidase antibody (TPO-Ab) OR thyroglobulin antibodies (Tg-Ab)] AND (levothyroxine OR euthyrox) AND [pregnancy outcome OR miscarriage OR abortion OR pregnancy loss OR preterm birth OR premature delivery OR early labo(u)r]. The reference lists of the relevant publications were also manually searched for related studies. Published manuscripts were included if they reported data on pregnancy loss, preterm birth or both. We separately analysed the pooled effects of LT4 supplementation on PLR and PBR in women with SCH and TAI.

OUTCOMES

Overall, 13 eligible studies including 7970 women were included in the meta-analysis. Eight and five of these studies were randomized controlled trials (RCTs) and retrospective studies, respectively. The pooled results indicated that LT4 supplementation significantly decreased the PLR [relative risk (RR) = 0.56, 95% confidence interval (CI): 0.42-0.75, I2 = 1%, 12 studies] and PBR (RR = 0.68, 95% CI: 0.51-0.91, I2 = 21%, eight studies) in women with SCH and/or TAI. We further found that LT4 supplementation significantly decreased the risk of pregnancy loss (RR = 0.43, 95% CI: 0.26-0.72, P = 0.001, I2 = 0%) but not of preterm birth (RR = 0.67, 95% CI: 0.41-1.12, P = 0.13, I2 = 0%) in women with SCH. Furthermore, LT4 supplementation significantly decreased the risks of both pregnancy loss (RR = 0.63, 95% CI: 0.45-0.89, P = 0.009, I2 = 0%) and preterm birth (RR = 0.68 95% CI: 0.48-0.98, P = 0.04, I2 = 46%) in women with TAI. These results were consistent when only RCTs were included in the analysis. Further, in women with SCH, LT4 supplementation reduced the risk of pregnancy loss in pregnancies achieved by assisted reproduction (RR = 0.27, 95% CI: 0.14-0.52, P < 0.001, I2 = 14%) but not in naturally conceived pregnancies (RR = 0.60, 95% CI: 0.28-1.30, P = 0.13, I2 = 0%). By contrast, in women with TAI, LT4 supplementation reduced the risks of both pregnancy loss (RR = 0.61, 95% CI: 0.39-0.96, P = 0.03, I2 = 0%) and preterm birth (RR = 0.49, 95% CI: 0.30-0.79, P = 0.003, I2 = 0%) in naturally conceived pregnancies but not in pregnancies achieved by assisted reproduction (RR = 0.68, 95% CI: 0.40-1.15, P = 0.15, I2 = 0% for pregnancy loss and RR = 1.20, 95% CI: 0.68-2.13, P = 0.53, I2 not applicable for preterm birth).

WIDER IMPLICATIONS

This meta-analysis confirmed the beneficial effects of LT4 supplementation, namely the reduced risks of pregnancy loss and preterm birth, among pregnant women with SCH and/or TAI. The different effects of LT4 supplementation on naturally conceived pregnancies and pregnancies achieved by assisted reproduction in women with SCH and/or TAI suggest that these women should be managed separately. Due to the limited number of studies included in this meta-analysis, especially in the subgroup analysis, further large RCTs and fundamental studies are warranted to confirm the conclusions and better clarify the molecular mechanism underlying these associations.

Impact of Thyroid Autoimmunity on Ovarian Reserve, Pregnancy Outcomes, and Offspring Health in Euthyroid Women Following In Vitro Fertilization/Intracytoplasmic Sperm Injection

Background: Thyroid autoimmunity (TAI) is the most frequent autoimmune disease among reproductive-aged women. It has been related to premature ovarian insufficiency, but the mechanisms remain elusive, and its association with ovarian reserve in euthyroid women is debatable. Moreover, the impact of TAI on assisted reproduction is controversial: especially for women with diminished ovarian reserve (DOR), few studies are available. Therefore, the present study was aimed to look for an association between TAI and DOR, and to evaluate the effect of TAI on pregnancy outcomes and offspring health following assisted reproductive technology stratified by ovarian reserve. Methods: A total of 6213 euthyroid women from the Reproductive Hospital Affiliated to Shandong University between 2012 and 2017 were retrospectively included. The prevalence of DOR in women with negative or positive TAI was calculated, and pregnancy and neonatal outcomes after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles were compared between the TAI-positive and TAI-negative groups both in women with DOR and in those with normal ovarian reserve (NOR). Longitudinal growth parameters and temperament type of the offspring were also observed in the TAI-positive and TAI-negative groups. Results: The prevalence of DOR in women with positive TAI and those with negative TAI was not significantly different (4.09% vs. 2.96%, p = 0.053), even after stratifying patients by age. In women with DOR, the live birth rate, pregnancy loss rate, neonatal complication rate, and offspring outcomes between the TAI-positive and TAI-negative groups were comparable (p > 0.05). In women with NOR, a higher rate of live births (44.94% vs. 40.34%, p = 0.027) and a higher prevalence of congenital anomalies (4.68% vs. 2.14%, p = 0.005) were observed in the TAI-positive group. Conclusions: TAI had no impact on ovarian reserve in euthyroid women and had no association with IVF/ICSI outcomes in women with DOR. Although an increased incidence of congenital anomalies in the TAI-positive group was observed in women with NOR, an association between neonatal anomalies and TAI cannot be demonstrated. Large cohort studies to evaluate the effects of TAI on offspring health are warranted, and further experimental studies are required to explore the underlying mechanisms.

The impact of thyroid autoantibodies on the cycle outcome and embryo quality in women undergoing intracytoplasmic sperm injection

Background

The influence of thyroid autoimmunity in in–vitro fertilization/intracytoplasmic sperm injection (ICSI) cycles is still a controversial issue. Although some women are euthyroid, some studies found thyroid dysfunction and thyroid autoimmunity increased the incidence of infertility. We aimed to evaluate the impact of anti-thyroid antibodies on the cycle parameters, embryo quality, and pregnancy outcomes in women who underwent ICSI cycles.

Results

Fertilization rate was significantly higher in anti-thyroid antibody-negative patients than in anti-thyroid antibody-positive patients (97.1 ± 10.5 vs. 91.5 ± 19.8, respectively, p = 0.003). Clinical pregnancy, miscarriage, and ongoing pregnancy rates were not different among study groups. The presence of top-quality embryo was lower in anti-thyroid antibody-positive patients but it did not reach any statistical significance (56.5% vs. 67.8%, p = 0.09). In the subgroup analysis, there were no significant differences except for the miscarriage rate according to the TSH threshold.

Conclusion

The clinical pregnancy and ongoing pregnancy were not affected by the positivity of anti-thyroid antibodies. We showed that thyroid autoimmunity may have an impact on fertilization rate and embryo quality in patients undergoing ICSI cycles. Miscarriage rate also increases with thyroid autoimmunity and TSH levels above 2.5 μIU/L.

Subclinical Hypothyroidism Is Associated with Lower Ovarian Reserve in Women Aged 35 Years or Older

Background: Overt thyroid diseases have been identified as risk factors for female infertility. However, it remains largely unclear whether subclinical hypothyroidism (SCH), a very common thyroid disorder, is associated with female infertility. This study aimed to investigate the potential association between SCH and the ovarian reserve in women seeking infertility treatment. Methods: This retrospective study included 2568 women with normal thyroid function (n = 2279) or SCH (n = 289) who visited our clinic for infertility treatment. Ovarian reserve markers, including follicle-stimulating hormone (FSH) concentrations on days 2-4, the antral follicle count (AFC), and anti-Müllerian hormone (AMH) concentration, were compared between euthyroid women and those with SCH. Multiple linear and Poisson regression analyses were used to estimate the associations of SCH with ovarian reserve markers. These analyses were repeated separately in women aged <35 (n = 1349) and ≥35 years (n = 1219). Results: In the total study population, women with SCH had significantly lower AMH concentrations (median: 2.05 vs. 2.51 ng/mL, p = 0.015) and AFCs (median: 10.0 vs. 11.0, p = 0.013), compared with euthyroid women. In linear and Poisson regression analyses, SCH was significantly associated with a higher basal FSH concentration (mean difference = 1.13 mIU/mL [95% confidence interval (CI) 0.97 to 1.29 mIU/mL], p < 0.001), lower AMH concentration (mean difference = -0.27 ng/mL [CI -0.43 to -0.12 ng/mL], p = 0.001), and lower AFC (mean difference = -0.7 [CI -1.3 to -0.2], p = 0.005). In women aged ≥35 years, SCH was significantly associated with FSH (mean difference = 1.74 mIU/mL, p < 0.001) and AMH concentrations (mean difference = -0.40 mg/mL, p < 0.001) and AFC (mean difference = -0.8, p < 0.001). In women <35 years old, SCH was significantly associated with a higher FSH concentration (mean difference = 0.30 mIU/mL, p < 0.001), but not with AMH or AFC concentrations (p = 0.84 and 0.06, respectively). Thyroperoxidase antibody (TPOAb) positivity was not associated with measures of ovarian reserve. Conclusions: The data suggest that SCH is associated with decreased ovarian reserve during later reproductive age. TPOAb positivity was not associated with ovarian reserve. Future research is necessary to investigate the underlying molecular mechanisms regulating the diminished ovarian reserve in women with SCH and to evaluate whether levothyroxine supplementation may improve the ovarian function of women with SCH.

Ovarian Reserve and Serum Concentration of Thyroid Peroxidase Antibodies in Euthyroid Women With Different Polycystic Ovary Syndrome Phenotypes

Objective: It has been shown that women with polycystic ovary syndrome (PCOS), as well as Hashimoto's thyroiditis (HT), are characterized by increased incidence of infertility. Serum anti-Müllerian hormone (AMH), which reflects ovarian reserve, is elevated in PCOS women and is decreased in women with HT. The Rotterdam criteria recognize four clinical PCOS phenotypes, i.e., phenotypes A, B, C, and D. The aim of the present study was to investigate the relation between serum concentrations of thyroid peroxidase antibodies (TPOAbs) and ovarian reserve in different PCOS phenotypes. Patients and methods: We examined 141 women with PCOS [phenotype A was diagnosed in 67 (47.5%) women, phenotype B in 30 (21.3%), phenotype C in 28 (19.9%), and phenotype D in 16 (11.3%)] and 88 control subjects of similar age; all women were euthyroid. Serum concentrations of AMH, thyroid-stimulating hormone (TSH), thyroid hormones, and TPOAbs were assessed. Results: We observed positive serum TPOAbs in 21.9% women with PCOS and in 23.9% controls (p = 0.07). We did not find differences in the frequency of detection of positive serum TPOAbs between phenotypes A, B, and C and the control group (p > 0.05). We did not observe a difference in AMH levels between TPOAbs-positive and TPOAbs-negative women, both in the control group and the PCOS women (all p > 0.05). However, serum AMH concentration was markedly higher in the whole PCOS group (p < 0.01) and in phenotype A (p < 0.01) vs. controls when the serum concentration of TPOAbs was negative. In the groups with positive serum levels of TPOAbs, serum concentration of AMH did not differ between PCOS phenotypes and controls (p = 0.23). Additionally, we observed that serum AMH concentration was related to the level of TPOAbs in the PCOS group (r = -0.4, p = 0.02). Conclusions: The frequency of serum detection of positive TPOAbs did not differ between PCOS phenotypes with clinical/biochemical hyperandrogenism and the control group. The observation of the difference in serum AMH between the PCOS and control groups only in TPOAbs negative women together with the inverse relation of TPOAbs with serum AMH only in the PCOS group might suggest that ovarian reserve is influenced by TPOAbs in PCOS.

The pathogenic role of autoantibodies in recurrent pregnancy loss

In the present manuscript, we review the recent research investigating the pathogenic association between most studied autoantibodies and recurrent pregnancy loss. Pregnancy loss represents a common obstetric complication occurring in about 15%-25% of all clinically recognized pregnancies. The recurrence of pregnancy loss identifies a distinct clinical entity, that is recurrent pregnancy loss (RPL), affecting about 2%-4% of couples. Several factors, including age, chromosomal abnormalities, uterine anomalies, thrombophilic disorders, endocrinopathies, hormonal and metabolic disorders, infections, sperm quality, and lifestyle issues, are involved in RPL. The role of autoantibodies in RPL is only partially determined. In some cases (antiphospholipid antibodies [aPL]), their involvement is well established. In other cases (anti-thyroid autoantibodies, antinuclear, anti-transglutaminase, and anti-endomysial antibodies), it is still debated, despite multiple, although not fully conclusive, evidences strongly suggest a possible involvement in RPL. Further extensive research is needed to definitively confirm or exclude their actual role.

Serum and follicular fluid thyroid hormone levels and assisted reproductive technology outcomes

OBJECTIVE

The objective ofthis study was to assess the association between thyroid hormone (TH) levels in follicular fluid (FF) and serum and to determine whether THs impact assisted reproductive technology (ART) outcomes.

METHODS

This study enrolled 299 women undergoing ART. Blood samples were drawn on the day of human chorionic gonadotrophin (HCG) administrationand analysed for thyroid-stimulating hormone (TSH), thyroxine(T4), triiodothyronine(T3),free T4 (fT4),free T3(fT3), thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TGAb) levels. FF was obtained on the oocyte pick up (OPU) day and analysed forTSH, T4, T3, fT4, fT3, TPOAb, TgAb and estradiol levels.

RESULTS

(1) There were significant positive correlations between serum and FF TH and thyroid autoantibody levels. Statistically significant differences were discovered in serum and FF levels of TSH (p ≤ 0.001), T4 (p ≤ 0.001), T3 (p ≤ 0.001), TPOAbs (p ≤ 0.001) and TGAbs (p = 0.021). (2) Serum T4 levels [121.9(104.8,140.8) vs 114.1(98.6,130.6) nmol/l, p = 0.026], serum fT4 levels[(19.0(17.7,21.8) vs 18.6(17.0,20.1) pmol/l, p = 0.026], serum T4/T3 ratios [62.5 (55.7, 66.2) vs 59.4 (53.4, 64.9), p = 0.029], FF fT4 levels [19.0(17.5,21.3) vs 18.1(16.8,19.9) pmol/l, p = 0.009] and FF T4/T3 ratios [52.6 (46.4, 57.3) vs 50.0 (43.7, 53.1), p = 0.004] were significantly higher in the successful pregnancy group than the implantation failure group. (3) Spearman's rank correlation analysis revealed positive associations of both the FF T4/T3 ratio and serum TSH levels with the numbers of retrieved oocytes (total or MII) and embryos (fertilized, cleavage, and good quality).

CONCLUSIONS

TH levels in FF are strongly correlated with those in serum on the HCG day, and THs on the HCG day may affect ART outcomes.

[Relationship of the ovarian reserve with autoimmune thyroid diseases in the reproductive period]

AIM

To compare ovarian reserve in healthy women of reproductive age - carriers of antithyroid antibodies (ATA) and in healthy women of reproductive age negative for ATA.

MATERIALS AND METHODS

70 healthy women of young reproductive age in the state of euthyroidism (from 18 to 38 years old) were examined. Participants were divided into equal groups (n=35) depending on the status of the presence of antithyroid antibodies (AT-TPO, AT-TG). On the 2nd-4th days of the menstrual cycle, the following markers of the ovarian reserve were determined: serum levels of anti-Müllerian hormone (AMG), inhibin B, FSH, LH, estradiol, testosterone and progesterone, as well as ultrasound parameters - the number of antral follicles and the volume of the ovaries. In addition, to determine the predisposition to premature ovarian failure, an analysis was performed to the number of CGG repeats in the FMR1 gene.

RESULTS AND DISCUSSION

Statistically significantly differs such parameters as the level of estradiol and testosterone, while the differences were not clinically significant. All the parameters evaluated were within the normal range, the main predictors of the ovarian reserve (levels of AMG and inhibin B, the number of antral follicles) remained in the normal range. An increase in the number of repeats of CGG in the FMR1 gene was not detected in any of the participants in the study.

CONCLUSION

In healthy young reproductive age women, the status of ATA does not have a direct effect on the ovarian reserve.

Thyroxine replacement for subfertile women with euthyroid autoimmune thyroid disease or subclinical hypothyroidism

BACKGROUND

Thyroid disease is the second most common endocrine disorder affecting women of reproductive age. Subclinical hypothyroidism is diagnosed by an elevated thyroid-stimulating hormone concentration with a normal concentration of free thyroxine hormone. Autoimmune thyroid disease (ATD) is diagnosed by the presence of thyroid autoantibodies, regardless of thyroid hormone levels. Thyroxine may be a useful treatment for subfertile women with these two specific types of thyroid disease for improving pregnancy outcomes during assisted reproduction.

OBJECTIVES

To evaluate the efficacy and harms of levothyroxine replacement in subfertile women with subclinical hypothyroidism or with normal thyroid function and thyroid autoimmunity (euthyroid autoimmune thyroid disease, or euthyroid ATD) undergoing assisted reproduction.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers together with reference checking and contact with study authors and experts in the field to identify studies. We searched for all published and unpublished randomised controlled trials (RCTs) comparing thyroxine with no treatment or placebo, without language restrictions, from inception to 8 April 2019, and in consultation with the Cochrane CGF Information Specialist.

SELECTION CRITERIA

We included women undergoing assisted reproduction treatment, meaning both in vitro fertilisation and intracytoplasmic sperm injection, with a history of subfertility and with subclinical hypothyroidism or with euthyroid ATD. We excluded women with a previously known clinical hypothyroidism or already taking thyroxine or tri-iodothyronine. RCTs compared thyroxine (levothyroxine) with either placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary review outcomes were live birth and adverse events of thyroxine; our secondary outcomes were clinical pregnancy, multiple pregnancy and miscarriage.

MAIN RESULTS

The review included four studies with 820 women. The included studies were of overall low risk of bias. Using GRADE methodology, we assessed the quality of evidence for the primary outcomes of this review to be very low- to low-quality evidence. Evidence was downgraded for imprecision as it was based on single, small trials with wide confidence intervals (CI). We were able to include data from three of the four included studies.In one study of women with both subclinical hypothyroidism and positive or negative anti-TPO antibodies (autoimmune disease), the evidence suggested that thyroxine replacement may have improved live birth rate (RR 2.13, 95% CI 1.07 to 4.21; 1 RCT, n = 64; low-quality evidence) and it may have led to similar miscarriage rates (RR 0.11, 95% CI 0.01 to 1.98; 1 RCT, n = 64; low-quality evidence). The evidence suggested that women with both subclinical hypothyroidism and positive or negative anti-TPO antibodies would have a 25% chance of a live birth with placebo or no treatment, and that the chance of a live birth in these women using thyroxine would be between 27% and 100%.In women with normal thyroid function and thyroid autoimmunity (euthyroid ATD), treatment with thyroxine replacement compared with placebo or no treatment may have led to similar live birth rates (risk ratio (RR) 1.04, 95% CI 0.83 to 1.29; 2 RCTs, number of participants (n) = 686; I² = 46%; low-quality evidence) and miscarriage rates (RR 0.83, 95% CI 0.47 to 1.46, 2 RCTs, n = 686, I² = 0%; low-quality evidence). The evidence suggested that women with normal thyroid function and thyroid autoimmunity would have a 31% chance of a live birth with placebo or no treatment, and that the chance of a live birth in these women using thyroxine would be between 26% and 40%.Adverse events were rarely reported. One RCT reported 0/32 in the thyroxine replacement group and 1/32 preterm births in the control group in women diagnosed with subclinical hypothyroidism and positive or negative anti-TPO antibodies. One RCT reported 21/300 preterm births in the thyroxine replacement group and 19/300 preterm births in the control group in women diagnosed with positive anti-TPO antibodies. None of the RCTs reported on other maternal pregnancy complications, foetal complications or adverse effects of thyroxine.

AUTHORS' CONCLUSIONS

We could draw no clear conclusions in this systematic review due to the very low to low quality of the evidence reported.

Overtime trend of thyroid hormones and thyroid autoimmunity and ovarian reserve: a longitudinal population study with a 12-year follow up

BACKGROUND

Ovarian reserve, vital for reproductive function, can be adversely affected by thyroid diseases. Despite alternations of thyroid hormones with ageing, data on interactions between the overtime trend of thyroid functions and ovarian reserve status has rarely been reported. We aimed to examine the overtime trend of thyroid hormones, thyroid peroxidase antibody (TPO Ab) and their associations with ovarian reserve status, identified by levels of age specific anti-mullerian hormone (AMH) in reproductive aged women, who participated in 12-year cohort of Tehran Thyroid Study (TTS).

METHODS

Reproductive age women(n = 775) without any thyroid disease or ovarian dysfunction were selected from the Tehran Thyroid Study cohort. Participants were divided into four age specific AMH quartiles (Q1-Q4), Q1, the lowest and Q4, the highest. AMH was measured at the initiation of study and thyroid stimulating hormone (TSH), free T4 (FT4), and TPO Ab were measured at baseline and at three follow up visits.

RESULTS

At baseline, there was no statistically significant difference in thyroid hormones between women of the four quartiles, although TPO Ab levels were higher in women of Q1. During the follow ups, FT4 was decreased in all quartiles (p < 0.05), whereas TPO Ab increased in Q1 (p = 0.02). Odds ratio of overall TPO Ab positivity in women of Q1 was 2.08 fold higher than those in Q4. (OR: 2.08, 95%CI: 1.16, 3.72; p = 0.01).

CONCLUSION

Women with the lowest ovarian reserves had higher levels of TPO Ab, with a positive trend of this antibody overtime in comparison to other quartiles, indicating that this group may be at a higher risk of hypothyroidism over time.

The Impact of Autoantibodies on IVF Treatment and Outcome: A Systematic Review

The role of autoantibodies in in vitro fertilization (IVF) has been discussed for almost three decades. Nonetheless, studies are still scarce and widely controversial. The aim of this study is to provide a comprehensive systematic review on the possible complications associated to autoantibodies (AA) impeding the chances of a successful IVF cycle. An Embase, PubMed/Medline and Cochrane Central Database search was performed on 1 December 2018, from 2006 until that date. From the 598 articles yielded in the search only 44 relevant articles ultimately fulfilled the inclusion criteria and were qualitatively analyzed. Five subsets of results were identified, namely, thyroid related AA, anti-phospholipid antibodies, anti-nuclear antibodies, AA affecting the reproductive system and AA related to celiac disease. It may be implied that the majority of auto-antibodies exert a statistically significant effect on miscarriage rates, whereas the effects on clinical pregnancy and live birth rates differ according to the type of auto-antibodies. While significant research is performed in the field, the quality of evidence provided is still low. The conduction of well-designed prospective cohort studies is an absolute necessity in order to define the impact of the different types of autoantibodies on IVF outcome.

Effects of controlled ovarian stimulation on thyroid stimulating hormone in infertile women

OBJECTIVE

To study the effects of long-acting gonadotropin-releasing hormone agonist (GnRH-a) on thyroid function in euthyroid patients of in vitro fertilization (IVF)/ intracytoplasmic sperm injection of embryo transfer (ICSI-ET) and to investigate the timing and alteration of thyroid stimulating hormone (TSH) during controlled ovarian stimulation(COS).

MATERIALS AND METHODS

Euthyroid patients scheduled for IVF/ICSI were enrolled. Euthyroidism was defined as having no history of hypothyroidism with normal TSH before IVF. Long GnRH-a protocol was chosen as COS protocol. 207 patients were divided into two groups based on basal serum TSH level: group A with 0.35mIU/L＜TSH＜2.5mIU/L (n = 137) and group B with 2.5mIU/L ≤ TSH＜4.5mIU/L (n = 70). Serum TSH was tested on 6 time points: before COS (2-5days in menstrual cycle, before GnRH-a injection), Gn injection day 1, Gn injection day 5, human chorionic gonadotropin (HCG) day, 14 and 28 days after transplantation. The serum TSH, clinical pregnancy and abortion rate were investigated.

RESULT

The serum TSH value was significantly (P < 0.05) increased after injection of long-acting GnRH-a in all patients. Both groups had significant (P < 0.05) increases in serum TSH level after long-acting GnRH-a injection. The TSH level was increased in 131(63.3%) patients after GnRH-a injection, of which twenty (9.7%) had subclinical hypothyroidism with TSH level over 4.5 mIU/L. The other 76 (36.7%) patients had decreased TSH. In group A, 79 (57.7%) patients showed an increase of TSH, including three patients (2.2%) with simultaneous rise of TPOAb and four (2.9%) diagnosed of subclinical hypothyroidism with TSH level over 4.5 mIU/L, and the rest fifty-eight (42.3%) patients had decreased TSH with one patient with elevated TPOAb who was diagnosed with subclinical hyperthyroidism. In group B, fifty-two (74.3%) patients showed an increase of TSH, including thirteen (18.6%) patients with elevated TPOAb and sixteen (22.9%) patients diagnosed of subclinical hypothyroidism with TSH level over 4.5 mIU/L, and the rest eighteen (25.7%) patients had decreased TSH with one patient diagnosed with subclinical hyperthyroidism. Group B had a significant higher proportion of patients with elevated serum TSH than group A (P ＜ 0.05). Compared to the baseline level, serum TSH ascended distinctly and reached peak level on HCG day in all patients. Group A and B had similar trends of alteration. Patients in group A had significantly (P＜0.05) higher clinical pregnancy rate than in group B. No significant (P＞0.05) difference in abortion rate were observed between the two groups.

CONCLUSION

GnRH-a can significantly increase serum TSH levels with possible development of subclinical thyroid dysfunction. Infertile patients with serum TSH > 2.5 mIU/L are more susceptible to GnRH-a while patients with basal TSH less than 2.5 mIU/L may get a higher clinical pregnancy rate when receiving IVF/ICSI.

Does subclinical hypothyroidism and/or thyroid autoimmunity influence the IVF/ICSI outcome? Review of the literature

While overt hypothyroidism is a well-known risk factor for infertility, the association of subclinical hypothyroidism (SCH) or thyroid autoimmunity and reproductive failure has been still not elucidated. In this literature review, the current data on the effect of SCH and/or thyroid autoimmunity and human reproduction is presented. The main ART outcome measures are as follows: number of oocytes retrieved, fertilization rate, implantation rate, clinical pregnancy rate per embryo transfer, embryo quality, miscarriage rate, and live birth rate. Current guidelines on the management of women with SCH and/or thyroid autoimmunity undergoing ART cycles will be presented in this review.

Follicular fluid thyroid autoantibodies, thyrotropin, free thyroxine levels and assisted reproductive technology outcome

OBJECTIVE

Although there are substantial data linking thyroid autoimmunity (TAI) and infertility, data regarding assisted reproductive technology (ART) outcomes and TAI markers in follicular fluid (FF) of women undergoing ART are scarce. Objective of the study was to assess the association of the levels of thyroid autoantibodies in FF and ART outcome expressed as the achieved pregnancies.

METHODS

This study enrolled 52 women undergoing ART (26 TAI positive subjects and 26 age and body mass index matched TAI negative controls). Blood samples were drawn before the initiation of protocol for controlled ovarian stimulation, and thyrotropin (TSH), free triiodothyronine (fT3), free thyroxine (fT4), thyroid peroxidase antibodies (TPOAbs) and thyroglobulin antibodies (TgAbs) levels were measured. TSH, fT4, TPOAbs, TgAbs and progesterone levels were also measured in FF.

RESULTS

There were no significant differences between the groups regarding mean levels of FF TSH and FF fT4. Statistically significant correlation was discovered regarding the levels of serum and FF TPOAbs (0,961, p<0.001 in TAI positive, 0,438, p = 0.025 in TAI negative group) and TgAbs (0,945, p<0.001 in TAI positive, 0,554, p = 0.003 in TAI negative group). Pregnancies rates per initiated cycle and per embryotransfer cycle were significantly different between TAI positive and TAI negative group, (30.8% vs 61.5%), p = 0.026 and (34.8% vs 66.7%), p = 0.029, respectively. Multivariate analysis showed that TAI positive women had less chance to achieve pregnancy (p = 0.004, OR = 0.036, 95% CI 0.004-0.347).

CONCLUSIONS

Higher levels of thyroid autoantibodies in FF of TAI positive women are strongly correlated with serum levels and may have effect on the post-implantation embryo development.

Association of Thyroid Function and Autoimmunity with Ovarian Reserve in Women Seeking Infertility Care

BACKGROUND

While overt thyroid disease is a well known risk factor for infertility, the potential consequences of mild thyroid dysfunction or thyroid autoimmunity remain unknown. Experimental studies suggest a considerable role for thyroid hormone in the physiological mechanisms of ovarian reserve, but translation of such findings to human studies remains rare. A potential role for thyroid function in female reproduction could be especially relevant when the cause of infertility remains unknown, such as in women with diminished ovarian reserve (DOR) or unexplained infertility. The aims of this study were to investigate the association of thyroid function and autoimmunity with markers of ovarian reserve day 3 follicle-stimulating hormone (FSH) concentrations and antral follicle count (AFC), and to investigate whether thyroid function or autoimmunity may have different effects in women with DOR or unexplained infertility.

METHODS

Thyrotropin, free thyroxine, thyroxine, free triiodothyronine (fT3), triiodothyronine, thyroid peroxidase antibodies (TPOAbs), and thyroglobulin antibodies (TgAbs), as well as AFC and the day 3 FSH concentration, were measured among women seeking fertility treatment at the Massachusetts General Hospital Fertility Center. Multiple linear or mixed regression models were used to study the association of thyroid function or autoimmunity with AFC or day 3 FSH.

RESULTS

In the total study population (436 women, 530 AFC measurements), there was no association of thyroid function or TPOAb positivity with AFC. However, TgAb positivity was associated with a higher AFC (mean difference = 3.4 [95% confidence interval (CI) 1.8-5.1], p < 0.001). In women with DOR or unexplained infertility, lower fT3 and TPOAb positivity were associated with a lower AFC (fT3: continuous nonlinear association, p = 0.009; TPOAb positivity: -2.3 follicles [confidence interval -3.8 to -0.5], p = 0.01), while TgAb positivity was not associated with AFC. Neither thyroid function nor thyroid antibody positivity was associated with the day 3 FSH concentration.

CONCLUSIONS

This study found that lower fT3 and TPOAb positivity are associated with a lower AFC in women with DOR or unexplained infertility. Future studies are required to replicate these findings and further elucidate the role of TgAbs and underlying mechanisms through which thyroid function and autoimmunity is associated with ovarian reserve.

In vitro fertilization/intracytoplasmic insemination and thyroid function: reviewing the evidence

Recent findings, that specific G protein-coupled TSH receptors (TSHR) and the nuclear thyroid hormone receptors (THRs) are widely expressed in reproductive tissues, reveal the close links between hypothalamus-pituitary-thyroid and hypothalamus-pituitary-gonadal axes. It has been suggested that thyroid function as well as thyroid autoimmunity (TAI) have an impact on Assisted Reproduction Technology (ART) reproductive outcome. Lately, it became evident that ovarian stimulation (OS) may also have an impact on thyroid function. This narrative review describes the mutual interaction between thyroid function and OS, by reviewing the current evidence, assessing the pathophysiological links and arriving at practical recommendations.

The influence of thyroid autoimmunity on embryo quality in women undergoing assisted reproductive technology

The influence of thyroid autoimmunity in assisted reproductive technology (ART) outcome in euthyroid women is still controversial. In this study, we retrospectively evaluated embryo quality in 123 euthyroid women undergoing ART with or without thyroid autoantibodies (TAA). Embryo quality was assessed in 119 embryos of 29 infertile patients with TAA and in 394 embryos of 94 infertile patients without TAA. Our results showed not statistically significant differences in age, body mass index, anti-Müllerian hormone, follicle stimulating hormone, free triiodothyronine, and free thyroxine levels between cases and controls. Thyroid stimulating hormone was within the normal range, but significantly higher in TAA patients compared with the controls (2.4 ± 0.8 vs. 2 ± 0.9 mIU/L, respectively, p < .01). The number of oocytes picked up and fertilized was comparable between the two groups. Embryo quality was significantly impaired in women with at least one autoantibody (p < .001). Implantation rate, pregnancy rate, and ongoing pregnancy rate were comparable in the two groups. These results suggest a negative impact of thyroid autoimmunity in embryo quality in women undergoing ART even when thyroid function is normal.

Autoimmune thyroid disease during pregnancy

Understanding of changes in thyroid function and the consequences of thyroid disease during pregnancy has rapidly grown in the past two decades, and revised American Thyroid Association guidelines on this topic were published in 2017. This Review explores the association between thyroid autoimmunity and complications during and after pregnancy. Thyroid autoimmunity refers to the presence of antibodies to thyroperoxidase or thyroglobulin, or thyroid-stimulating hormone receptor antibodies (TRAbs), or a combination of these, and is present in up to 18% of pregnant women. Thyroid antibodies in pregnant women with normal functioning thyroids (ie, euthyroid) have been associated with several complications, including miscarriage and premature delivery. Treatments to improve pregnancy outcomes are being studied. Whether thyroid antibodies are associated with infertility and assisted reproductive technology outcomes is unclear; although, treatment with low doses of levothyroxine, which is usually used to treat hypothyroidism, can be considered in such situations. Additionally, thyroid antibodies have been associated with other neonatal and maternal complications. All these associations require confirmation in larger prospective studies, and their pathogenic mechanisms need to be better understood. Post-partum thyroiditis is substantially more frequent in women who have thyroid antibodies during pregnancy than in those who do not have thyroid antibodies; however, whether treatment can prevent post-partum thyroiditis in women who are or have been antibody positive is unknown. Finally, TRAbs cross the placenta from the mother to the fetus and can cause fetal or neonatal hyperthyroidism. Therefore, women who are positive for TRAbs during pregnancy should be monitored.

'Does levothyroxine improve pregnancy outcomes in euthyroid women with thyroid autoimmunity undergoing assisted reproductive technology?'

Evidence on the treatment of euthyroid infertile women and thyroid autoimmunity with thyroid hormone is scare, and therefore the recent study by Wang et al. is a welcome addition to it. Based on their results, thyroid hormone seems not to be indicated to decrease the miscarriage rate in that particular group of infertile women. This comment is meant to put the study results into perspective with the available evidence and the current guidelines, and to highlight its strengths and weaknesses.

Thyroid autoimmunity and intracytoplasmic sperm injection outcome: a systematic review and meta-analysis

BACKGROUND

Since 2010, three meta-analyses have been published on the impact of thyroid autoimmunity (TAI) on pregnancy outcomes in infertile women treated with assisted reproductive technology (ART). The initially observed high risk of miscarriage became very low in the most recent meta-analysis published in 2016.

OBJECTIVE

To investigate whether the lower risk of miscarriage in the latest meta-analysis was associated with the increased use of intracytoplasmic sperm injection (ICSI) in recent studies.

DATA SOURCE

MEDLINE was searched from January, 1990, to May, 2017.

STUDY SELECTION

Data from case-control and cohort studies, on ART (IVF/ICSI) pregnancy outcomes in women with and without TAI. Only studies were included in which women were treated with ICSI.

DATA EXTRACTION AND SYNTHESIS

Four studies were retained including 1855 ICSI cycles (290 with and 1565 without TAI). In women with a clinical pregnancy (114 ICSI cycles with TAI and 651 without), there was no difference in miscarriage or live birth rates: respective combined OR 0.95 (95% CI, 0.48 to 1.87) and 1.12 (95% CI, 0.62 to 2.03). There was no difference in age in women with and without TAI: combined mean difference of 0.13 years (95% CI, -0.51 to 0.76), but serum TSH was higher in women with TAI: combined mean difference of 0.20 mIU/L (95% CI, 0.07 to 0.33).

CONCLUSION

Infertile women with TAI treated with ICSI had no increased risk of a first trimester miscarriage compared with women without TAI.

Levothyroxine supplementation improves serum anti-Müllerian hormone levels in infertile patients with Hashimoto's thyroiditis

AIM

Thyroid dysfunction and autoimmunity are associated with an adverse effect on fertility. An aberrant high thyroid stimulating hormone level is associated with diminished ovarian reserve in women of reproductive age; however, the utility of levothyroxine (LT4) replacement for infertile patients with subclinical hypothyroidism is still under discussion. The aim of this study was to investigate whether LT4 supplementation for infertile patients with subclinical hypothyroidism improves impaired ovarian function.

METHODS

We measured levels of serum thyroid-related hormones and a biomarker of ovarian function, anti-Müllerian hormone (AMH) in infertile women from 2014 to 2015. Out of a consecutive 1431 infertile patients, 311 patients with an elevated thyroid stimulating hormone level (≥ 2.5 μIU/mL) underwent detailed thyroid examinations, including blood tests of thyroid antibodies. We recruited 174 infertile patients, excluding patients with factors impacting ovarian and thyroid function. We evaluated alterations in AMH and thyroid related hormone levels during LT4 supplementation and infertility treatment with assisted reproductive technology.

RESULTS

After LT4 supplementation, no significant change in the average AMH level was detected overall. However, the AMH level in 35 patients with Hashimoto's disease increased significantly after treatment (1 month 1.3 ± 0.5 fold, P = 0.007; 3 months 1.3 ± 0.4 fold, P = 0.040). The AMH level in patients with thyroglobulin antibody-positive and thyroid peroxidase antibody-negative also significantly increased after LT4 treatment (1 and 3 months 1.5 fold; P = 0.023).

CONCLUSION

In the patients with Hashimoto's disease, preconception LT4 treatment may relieve adverse effects, including autoimmune antibodies, and support follicular development.

There is no association between the presence of anti-thyroid antibodies and increased reproductive loss in pregnant women after ART: a systematic review and meta-analysis

Women submitted to ART treatments represent a select subgroup of individuals. Several studies have described the relationship between TAI and pregnancy outcomes as a result of ART, with contradictory results. The purpose of this systematic review was to determine the association between TAI and the risk of miscarriage in pregnancies resulting from ART. MEDLINE via PubMed, LILACS and Embase were searched for studies published in peer-reviewed journals from 1999 to 2017. The studies were summarized using the fixed effects model and the Peto's method to calculate RR in order to flesh out the association between TAI and spontaneous abortion. Only four papers were included in this systematic review and meta-analysis. Thirty-one miscarriages were observed in 210 clinical pregnancies of women with antithyroid antibodies; and 158 miscarriages were seen in 1,371 pregnancies without antithyroid antibodies. The meta-analysis failed to find an association between TAI and higher risk of reproductive loss, RR=0.94 95% confidence interval: 0.71-1.24; p=0.879. In conclusion, the presence of antithyroid antibodies was not associated with increased reproductive loss in patients submitted to ART treatments. It is our opinion that the presence of antithyroid antibodies should be considered as a secondary biomarker of autoimmune disease, rather than an actual cause of miscarriage in patients undergoing ART. Due to the small amount of evidence on the matter, the determination of TAI before the initiation of ART should be limited to research contexts.

Impact of thyroid autoimmunity in euthyroid women on live birth rate after IUI

Study question

Does thyroid autoimmunity (TAI) predict live birth rate in euthyroid women after one treatment cycle in IUI patients?

Summary answer

TAI as such does not influence pregnancy outcome after IUI treatment.

What is known already

The role of TAI on pregnancy outcome in the case of IVF/ICSI is largely debated in the literature. This is the first study to address this issue in the case of IUI.

Study design, size, duration

This was a retrospective cohort study. A two-armed study design was performed: patients anti-thyroid peroxidase (TPO)+ and patients anti-TPO-. All patients who started their first IUI cycle in our fertility center between 1 January 2010 and 31 December 2014 were included. After exclusion of those patients with or being treated for thyroid dysfunction, 3143 patients were finally included in the study.

Participants/materials, setting, methods

After approval by the institutional review board we retrospectively included all patients who started their first IUI cycle in our center between 1 January 2010 and 31 December 2014 with follow-up of outcome until 31 December 2015. Patients with clinical thyroid dysfunction were excluded (thyroid-stimulating hormone (TSH) <0.01 mIU/l; TSH >5 mIU/l) as were patients under treatment with levothyroxine or anti-thyroid drugs. These patients were then divided into two main groups: patients anti-TPO+ and patients anti-TPO- (= control group). Live birth delivery after 25 weeks of gestation was taken as the primary endpoint of our study. As a secondary endpoint, we evaluated differences in live birth delivery after IUI according to different upper limits of preconception TSH thresholds (<2.5 and <5.0 mIU/l). Furthermore, the influence of thyroid function (TSH, free thyroxine (fT4)), anti-TPO status, age, smoking, BMI, parity, ovarian reserve (anti-mullerian hormone (AMH) and FSH), IUI indication and IUI stimulation on live birth rate was analyzed.

Main results and the role of chance

Between-group comparison did not show any significant difference between the anti-TPO+ and anti-TPO- group with respect to live birth delivery-, pregnancy- or miscarriage rate with odds ratio at 1.04 (95% CI: 0.63; 1.69), 0.98 (95% CI: 0.62; 1.55) and 0.74 (95% CI: 0.23; 2.39), respectively. In addition, there were no significant differences in live birth delivery-, pregnancy- or miscarriage rate when comparing subgroups according to TSH level (TSH ≥2.5 mIU/l vs. TSH <2.5 mIU/l) with an odds ratio at 1.05 (95% CI: 0.76; 1.47), 1.04 (95% CI: 0.77; 1.41) and  0.95 (95% CI: 0.47; 1.94), respectively.

Limitations, reasons for caution

This study was powered for the primary aim, live birth rate. The limitations of this study are the absence of region-specific reference ranges for thyroid hormones and the absence of follow-up of TSH values during ART and subsequent pregnancy. Moreover, there was a time difference of 5 months between thyroid assessment and the start of stimulation. The area where the study was conducted corresponds to a mild iodine deficient area and data should be translated with caution to areas with different iodine backgrounds.

Wider implications of the findings

Our findings indicate comparable pregnancy-, abortion- and delivery rates in women with and without TAI undergoing IUI. Moreover, we were unable to confirm a negative effect of TSH level above 2.5 mIU/l on live birth delivery rate. We therefore believe that advocating Levothyroxine treatment at TSH levels between 2.5 and 4 mIU/l needs to be considered with caution and requires further analysis in a prospective cohort study.

Study funding/competing interest(s)

No external funding was used for this study. No conflicts of interest are declared.

Idiopathic Low Ovarian Reserve Is Associated with More Frequent Positive Thyroid Peroxidase Antibodies

BACKGROUND

While screening of thyroid peroxidase antibody (TPOAb) has been recommended in women with primary ovarian insufficiency, the relationship between thyroid autoimmunity (TAI) and ovarian reserve remains undetermined. Because the TAI prevalence was reported to be different between different ethnic/racial groups, this study aimed to investigate the TAI prevalence in Chinese women with variable ovarian reserve.

METHODS

This is a cross-sectional study conducted in a university infertility clinic between October 2013 and March 2016. Among patients at their first entry to the infertility clinic, a total of 1044 patients with available results of anti-Müllerian hormone (AMH), thyrotropin (TSH), TPOAb, and thyroglobulin antibody (TgAb) were enrolled. The TSH levels and the prevalence of positive TPOAb and positive TgAb were compared between patients with low, normal, and high ovarian reserve categorized with age-specific AMH levels.

RESULTS

For the whole study population, the TSH levels, TPOAb positivity, and TgAb positivity were comparable between patients with variable ovarian reserve. However, after patients with known causes compromising ovarian reserve (iatrogenic or genetic) were excluded, only TPOAb positivity became significantly different between patients with low (22.7%), normal (14.0%), and high ovarian reserve (10.3%; p = 0.012). The TPOAb levels were not significantly correlated to AMH levels (Spearman's ρ = -0.027; p = 0.413). For the infertile subgroup, TPOAb positivity was significantly associated with idiopathic low ovarian reserve in unexplained infertility (low ovarian reserve: 28.6%; normal: 15.7%; high: 9.5%; p = 0.020).

CONCLUSIONS

Idiopathic low ovarian reserve was associated with more frequent positive TPOAb rather than thyroid function or TgAb positivity in Chinese women.

Thyroid peroxidase identified in human granulosa cells: another piece to the thyroid-ovary puzzle?

Thyroid hormones seemingly influence the maturation of the human oocyte. Thyroid hormone receptors have been isolated in granulosa mural and cumulus cells and the mature oocyte of the human ovarian follicle. Thyroid hormones are present in follicular fluid in concentrations similar to those in serum. Most importantly, enzymes involved in the chain that regulate the generation of thyroid hormones have been found in granulosa cells. For the first time, we have isolated thyroid peroxidase by immunocytochemistry in the granulosa cumulus cells of the human ovarian follicle, thereby supporting the hypothesis that the human ovarian follicle may be an independent thyroid-hormone producing unit.

Effect of thyroid autoimmunity per se on assisted reproduction treatment outcomes: A meta-analysis

OBJECTIVE

Thyroid autoimmunity (TA) is the most prevalent autoimmune disease in women of reproductive age and is often accompanied by subclinical hypothyroidism (SCH). Both TA and SCH have been associated with adverse pregnancy outcomes, but their relative influence is unclear. Therefore, we carried out a meta-analysis to evaluate the sole effect of TA on pregnancy outcomes in euthyroid women undergoing assisted reproductive technology.

MATERIALS AND METHODS

Literature searches were conducted on Pubmed, EMBASE, and the Cochrane Controlled Trials Register Database from inception to May 2014.

RESULTS

In euthyroid women whose SCH status is unknown, those with positive antithyroid antibodies (ATA) had a higher miscarriage rate [pooled relative risk (RR) = 1.638; 95% confidence interval (CI), 1.228-2.185] and a lower delivery rate (pooled RR = 0.856; 95% CI, 0.759-0.965) than those with negative ATA. Clinical pregnancy rates were similar between groups. However, clinical pregnancy rate, miscarriage rate, and delivery rate were all comparable between ATA-positive and ATA-negative euthyroid women without SCH.

CONCLUSION

TA per se does not impair assisted reproductive treatment outcomes in women without SCH.

2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum

BACKGROUND

Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.

The impact of thyroid autoimmunity on IVF/ICSI outcome: a systematic review and meta-analysis

BACKGROUND

Thyroid autoimmunity (TAI) is the most frequent autoimmune condition and the first cause of thyroid dysfunction among women of reproductive age. Notably, it has been associated with adverse obstetric outcomes during all trimesters of pregnancy. Furthermore, since most studies show an increased prevalence of TAI among women attending infertility clinics, a detrimental impact of this condition on natural fertility and on the rate of success of assisted reproductive techniques has been suggested. However, to date, the results have been inconsistent.

OBJECTIVE AND RATIONALE

The objective of this study was to define the relation between TAI per se and the outcome of in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) cycles.

SEARCH METHODS

A systematic literature review and meta-analysis were conducted. A Medline search was performed to identify all the comparative studies published from January 1990 to November 2015 in the English language literature on IVF/ICSI outcome in women with and without TAI, using combinations of the medical subject heading terms 'thyroid autoimmunity', 'thyroid autoantibodies', 'IVF', 'ICSI', 'pregnancy', 'miscarriage' and 'delivery'. The primary outcome was live birth rate (LBR). Our secondary outcomes were number of oocytes retrieved (NOR), fertilisation rate (FR), implantation rate (IR), clinical pregnancy rate (CPR) and miscarriage rate (MR). We also extracted data on mean age and basal serum concentrations of thyroid stimulating hormone (TSH) and performed a meta-regression analysis to assess the effect of these two covariates on CPR and MR.

OUTCOMES

We selected 12 studies for the meta-analysis. Six of the included studies were prospective cohort studies, and six were retrospective cohort studies. Compared with women with negative TAI, women with positive TAI had a lower LBR (odds ratio (OR) 0.73; 95% confidence interval (CI) [0.54-0.99]; P = 0.04; 9 studies; 4396 women; I2 = 41%), a higher MR (OR 1.44; 95% CI [1.06-1.95]; P = 0.02; 12 studies; 4876 women; I² = 35%), a similar CPR (OR 0.90; 95% CI [0.77-1.06]; P = 0.22; 12 studies; 4876 women; I² = 7%), a similar number of oocytes (standardized mean difference [SMD] 0.10; 95% CI [-0.09 to 0.29]; P = 0.28; 5 studies; 1506 women; I² = 47%), a similar FR (OR 1.11; 95% CI [0.97-1.27]; P = 0.13; 3 studies; 1082 women; I² = 0%) and a similar IR (OR 0.98; 95% CI [0.73-1.32]; P = 0.91; 2 studies; 918 women; I² = 0%). Both mean age (SMD 0.96; 95% CI [0.66-1.27]; P < 0.00001; 9 studies; 3256 women; I² = 85%) and serum TSH (SMD 0.24; 95% CI [0.15-0.34]; P < 0.00001; 6 studies; 2098 women; I² = 59%) were higher in women with TAI. However, neither of these two covariates were significantly associated with CPR or MR.

WIDER IMPLICATIONS

TAI does not impact on IVF/ICSI outcome in terms of NOR and likelihood of fertilisation, implantation and clinical pregnancy. On the contrary, the presence of thyroid autoantibodies may have a detrimental effect on the course of a pregnancy, determining an increased risk of miscarriage and a decreased chance of live birth. However, given the possible modifying effects of age and serum TSH, further evidence is warranted prior to drawing inferences on causality.

[Thyroid function for infertile women during ovarian hyperstimulation as part of IVF]

OBJECTIVES

Optimal thyroid function is necessary for an effective fertility. Many authors have suggested that thyroid function has an impact on IVF outcome. Conversely, IVF has been suggested to induce changes in thyroid function. The aim of this study was to determine the nature and the timing of alterations in thyroid function, throughout controlled ovarian hyperstimulation, from the beginning of therapy to the day of triggering ovulation. And make a clarification of the current recommendations of the thyroid function during hormonal stimulation.

METHODS

Subjects were recruited from March 2013 to July 2013 at the Hospital of the University of Reims. The studied population consisted of 50 infertile patients who had undergone IVF/ICSI cycles. Thyroid axis exploration was realized before therapy and at every hormonal dosage during ovarian monitorage.

RESULTS

Prematuary fluctuations were observed without impact on pregnancy rate. We could detect potential hypothyroid women thanks to this dosage and define a connection between pregnancy rate and TSH with a threshold closer to 1mUI/L than 2,5mUI/L defined by the endocrine society.

CONCLUSIONS

The link between thyroid function, forecast of conception and pregnancy is well documented. Currently, there is no recommendation on the rate of TSH targets for the patients in medical assisted procreation.

Anti-laminin-1 antibodies in serum and follicular fluid of women with Hashimoto's thyroiditis undergoing in vitro fertilization

The aim of this study is to evaluate the presence of anti-laminin-1 antibodies (aLN-1) in sera and follicular fluid (FF) of infertile women affected by Hashimoto's thyroiditis (HT) undergoing in vitro fertilization (IVF) and its impact on oocyte maturation and IVF outcome. aLN-1 were measured by a home-made enzyme linked immunosorbent assay (ELISA) in: (1) sera and FF from 44 infertile women affected by HT (HTIW) with tubal factor or male factor as primary cause of infertility; (2) in sera and FF from 28 infertile women without HT, with tubal factor or male factor as cause of infertility (infertile controls-ICTR); and (3) in sera from 50 fertile women (FW). aLN-1 serum levels were significantly higher in HTIW when compared with both fertile women and ICTR (P <0.001and P <0.01, respectively). Assuming as cutoff the 99th percentile of values obtained in sera of FW, 43.2% of HTIW and 3.6% of ICTR were aLN-1 positive (P = 0.0001). Also aLN-1 detected in FF from HTIW were significantly higher in comparison with those found in FF of ICTR (P = 0.006). In HTIW, metaphase II oocyte count showed inverse correlation with both serum and FF aLN-1 levels (r = 0.34, P = 0.02 and r = 0.33, P = 0.03, respectively). Implantation and pregnancy rates were significantly lower in HTIW (7.9% and 9.1%, respectively) when compared with ICTR (23% and 31.1%, respectively) (P = 0.015 and P = 0.03, respectively). Our results demonstrated for the first time the presence of aLN-1 in a relevant percentage of HTIW and suggest that these auto-antibodies may impair IVF outcome.

Thyroid dysfunction and subfertility

The thyroid hormones act on nearly every cell in the body. Moreover, the thyroid gland continuously interacts with the ovaries, and the thyroid hormones are involved in almost all phases of reproduction. Thyroid dysfunctions are relatively common among women of reproductive age, and can affect fertility in various ways, resulting in anovulatory cycles, high prolactin levels, and sex hormone imbalances. Undiagnosed and untreated thyroid disease can be a cause of subfertility. Subclinical hypothyroidism (SCH), also known as mild thyroid failure, is diagnosed when peripheral thyroid hormone levels are within the normal reference laboratory range, but serum thyroid-stimulating hormone levels are mildly elevated. Thyroid autoimmunity (TAI) is characterized by the presence of anti-thyroid antibodies, which include anti-thyroperoxidase and anti-thyroglobulin antibodies. SCH and TAI may remain latent, asymptomatic, or even undiagnosed for an extended period. It has also been demonstrated that controlled ovarian hyperstimulation has a significant impact on thyroid function, particularly in women with TAI. In the current review, we describe the interactions between thyroid dysfunctions and subfertility, as well as the proper work-up and management of thyroid dysfunctions in subfertile women.

The impact of the presence of antithyroid antibodies on pregnancy outcome following intracytoplasmatic sperm injection-ICSI and embryo transfer in women with normal thyreotropine levels

PURPOSE

The aim of our study was to investigate the impact of anti-thyroid peroxidase antibodies (Anti-TPO) on pregnancy outcome following the in vitro fertilization and embryo transfer (IVF-ET) in general groups and in subgroups divided according to AMH level and age.

METHODS

A total of 114 patients positive for anti-thyroid peroxidase antibodies (Anti-TPO+ group) and 495 infertile women negative for anti-thyroid peroxidase antibodies (Anti-TPO- group) undergoing IVF with ICSI from April 2010 to April 2012 were analyzed retrospectively.

RESULTS

There were no significant differences in age, BMI, basal FSH, LH, AMH levels and duration of infertility between the two main groups. No significant differences in terms of the days of ovarian stimulation, estradiol level in day 8, total gonadotropin dose, number of oocytes retrieved, available embryos and blastocysts, number of embryos transferred nor in rates of fertilization, implantation, clinical pregnancy, live birth and abortion rate between two main groups were found. The only statistically significant difference among the groups with different anti-TPO antibodies levels was found in basal FSH concentration and BMI. Among the clinical outcomes of IVF with respect to the different anti-TPO levels, the only significant difference was found for the number of oocytes retrieved. Analysis of the baseline parameters in relationship to age categories and AMH levels found significant differences between women positive and negative for thyroid antibodies with respect to basal FSH and LH levels for women >37 years and for basal FSH in AMH <0.6 subgroup.

CONCLUSIONS

The present study reveals that patients with anti-TPO antibodies showed no significant differences in fertilization, implantation, pregnancy rates, live birth rates and no higher risk for miscarriage following IVF-ET when compared with those negative for anti-thyroid antibodies.

The impact of thyroid function and thyroid autoimmunity on embryo quality in women with low functional ovarian reserve: a case-control study

BACKGROUND

Women with hyper-and hypothyroidism are at increased risk for infertility and adverse pregnancy outcomes. Whether in women considered euthyroid thyroid function (TSH values) and thyroid autoimmunity (thyroid antibodies) influence in vitro fertilization (IVF) cycle outcome has, however, remained controversial. Any such effect should be easily visible in women with low functional ovarian reserve (LFOR) and thus small oocyte and embryo numbers.

METHODS

We evaluated the relationship between TSH levels and embryo quality in euthyroid women with LFOR undergoing IVF. Mean age for the study population was 39.9±4.6 years. Embryo quality was assessed in 431 embryos from 98 first IVF cycles according to TSH levels (with cut-off 2.5μIU/mL), and to presence versus absence of thyroid autoantibodies.

RESULTS

Mean Anti Mullerian hormone (AMH) was 0.8±0.8 ng/mL and mean TSH was 1.8±0.9 μIU/mL. Comparable embryo quality was observed in women with TSH≤ and >2.5μIU/mL. TPO antibodies significantly affected embryo quality in women with low-normal TSH levels (P=0.045). In women with high-normal TSH levels, increasing TSH had a negative impact on embryo quality (P=0.027). A trend towards impaired embryo quality with TPO antibodies was also observed in these patients (p=0.057).

CONCLUSIONS

TPO antibodies affect embryo quality in euthyroid women with low-normal TSH≤2.5 μIU/mL. In women with high-normal TSH levels, increasing TSH levels, and possibly TPO antibodies, appear to impair embryo quality. These results suggest that the negative impact of thyroid autoimmunity becomes apparent, once thyroid hormone function is optimized.

Pathophysiological aspects of thyroid hormone disorders/thyroid peroxidase autoantibodies and reproduction

BACKGROUND

Thyroid hormone disorders and thyroid peroxidase autoantibodies (TPO-Ab) in women are associated with subfertility and early pregnancy loss. Here, we aim to provide a comprehensive overview of the literature on the pathophysiology of these associations.

METHODS

A review of the literature in the English language was carried out. Relevant studies were identified by searching Medline, EMBASE and the Cochrane Controlled Trials Register from 1975 until March 2014.

RESULTS

From a total of 6108 primary selected articles from the literature search, 105 articles were selected for critical appraisal. Observational data indicate that altered thyroid hormone levels are associated with disturbed folliculogenesis, spermatogenesis, lower fertilization rates and lower embryo quality. Triiodothyronine (T3) in combination with FSH enhances granulosa cell proliferation and inhibits granulosa cell apoptosis by the PI3K/Akt pathway. T3 is considered a biological amplifier of the stimulatory action of gonadotrophins on granulosa cell function. T3 increases the expression of matrix metalloproteinases (MMP), MMP-2, MMP-3, fetal fibronectin and integrin α5β1T3 in early placental extravillous trophoblasts. Thyroid hormone transporters and receptors are expressed in the ovary, early embryo, endometrium, uterus and placenta. No other data explaining the associations could be retrieved from the literature. The presence of TPO-Ab is negatively associated with spermatogenesis, fertilization and embryo quality, but no data are available on the potential pathophysiological mechanisms.

CONCLUSIONS

Thyroid hormone disorders and TPO-Ab are associated with disturbed folliculogenesis, spermatogenesis, fertilization and embryogenesis. The pathophysiology of these associations remains largely unknown, as evidence is limited and includes studies using small sample sizes, and often restricted to animal models. There are no studies on the pathophysiology underlying the association between TPO-Ab and reproduction. The available evidence, although limited, supports a role of thyroid hormone in fertility and early pregnancy. This justifies clinical intervention studies on the effects of thyroid hormone supplementation in women with subclinical hypothyroidism and in women prone to develop hypothyroidism due to the presence of TPO-Ab. In addition, more research is needed to identify the underlying mechanisms. This would be of particular interest in women undergoing IVF to pinpoint the effects of thyroid hormone on different parameters of reproduction.

High Prevalence of Infertility among Women with Graves' Disease and Hashimoto's Thyroiditis

Objectives. To evaluate the prevalence of infertility in women with Graves' disease (GD) or Hashimoto's thyroiditis (HT) and associated factors. Material and Methods. This cross-sectional study was conducted at the Endocrinology Clinic for Thyroid Autoimmune Diseases, with 193 women aged 18-50 years with GD and 66 women aged 18-60 years with HT. The women were interviewed to obtain data on their gynecological and obstetric history and family history of autoimmune diseases. Their medical records were reviewed to determine the characteristics of the disease and to confirm association with other autoimmune diseases. Infertility was defined as 12 months of unprotected sexual intercourse without conception. Results. The prevalence of infertility was 52.3% in GD and 47.0% in HT. Mean age at diagnosis was 36.5 years and 39.2 years, in GD and HT, respectively. The mean number of pregnancies was lower in women who were 35 years old or younger at diagnosis and was always lower following diagnosis of the disease, irrespective of age. The only variable associated with infertility was a shorter time of the disease in HT. Conclusions. The prevalence of infertility was high in women with GD and HT and affected the number of pregnancies in young women.

Screening for autoimmune thyroid disorders after spontaneous abortion is cost-saving and it improves the subsequent pregnancy rate

Background

Hypothyroidism and/or autoimmune thyroid disorders (AITD) may contribute to spontaneous abortions (SpA). Cost-effectiveness analyses of thyroid screening in women after SpA are lacking. Our aim was to evaluate the cost-effectiveness of screening for AITD and/or hypothyroidism and their treatment in women after SpA with regard to their reproductive health.

Methods

We performed a cross-sectional non-randomized study with follow-up in 2008–2011 in the settings of Departments of Endocrinology and Obstetrics/Gynecology of a university hospital. We enrolled 258 women after SpA before the 12th gestational week and followed them for a median of 3 years. At enrollment, serum concentrations of thyroid stimulatory hormone (TSH), antibodies to thyroid peroxidase (TPOAb) and free thyroxine (FT4) were measured and thyroid ultrasound performed. Women with overt hypothyroidism were treated with levothyroxine (n = 45; 61.6%) and women with subclinical hypothyroidism or euthyroid AITD were treated (n = 28; 38.4%) or left untreated (n = 38; 14.7%). Euthyroid women without signs of AITD served as controls (n = 147; 57.0%).

Results

Of the 38 untreated women with AITD and/or subclinical hypothyroidism, 8 (21.1%) reported secondary infertility as compared to 16/147 (10.9%) controls and 3/73 (4.1%) treated women (p = 0.021). Treatment was associated with an increased rate of successfully completed subsequent pregnancies (increment of 6 newborns/100 women) and a savings of €19,539/100 women. Total costs per successfully completed pregnancy were €1,189 in controls, €1,564 in the treated, and €2,488 in the untreated women.

Conclusions

Screening for thyroid disorders in women after SpA and treatment with levothyroxine is cost-saving and it improves the subsequent pregnancy rate.