The role of magnesium and thyroid function in early pregnancy after in-vitro fertilization (IVF): New aspects in endocrine physiology

Practical Guidelines for Diagnosing and Treating Thyroid Disease Based on the WOMED Metabolic Model of Disease Focusing on Glycolysis and Coenzyme Q10 Deficiency—A Clinical Alternative to the 2021 Retired Clinical Practice Guidelines of the Endocrine Society

This review aims to provide a functional, metabolic view of the pathogenesis of benign thyroid disease. Here, we summarize the features of our previous publications on the “WOMED model of benign thyroid disease”. As of 2021, the current state of art indicates that the basic alteration in benign thyroid disease is a metabolic switch to glycolysis, which can be recognized using 3D-power Doppler ultrasound. A specific perfusion pattern showing enlarged vessels can be found using this technology. This switch originates from an altered function of Complex I due to acquired coenzyme Q₁₀ deficiency, which leads to a glycolytic state of metabolism together with increased angiogenesis. Implementing a combined supplementation strategy that includes magnesium, selenium, and CoQ₁₀, the morphological and perfusion changes of the thyroid can be reverted, i.e., the metabolic state returns to oxidative phosphorylation. Normalization of iron levels when ferritin is lower than 50 ng/mL is also imperative. We propose that a modern investigation of probable thyroid disease requires the use of 3D-power Doppler sonography to recognize the true metabolic situation of the gland. Blood levels of magnesium, selenium, CoQ₁₀, and ferritin should be monitored. Thyroid function tests are complementary so that hypo- or hyperthyroidism can be recognized. Single TSH determinations do not reflect the glycolytic state.

Effect of thyroid function on assisted reproduction outcomes in euthyroid infertile women: A single center retrospective data analysis and a systematic review and meta-analysis

BACKGROUND

The influence of thyroid-stimulating hormone (TSH) on gestational outcomes have been studied and checked whether differing TSH levels are relevant on human reproduction outcomes. International guidelines recommend TSH values <2.5 mIU/L in women trying to conceive, since values above this level are related to a higher frequency of adverse reproductive outcomes. This study aimed to evaluate whether TSH values correlate with different gestational outcomes in euthyroid infertile women without autoimmune thyroid disease.

METHODS

A retrospective cohort study was conducted involving 256 women who underwent in vitro fertilization (IVF) treatment. The participants were divided into two groups: TSH 0.5-2.49 mIU/L (n=211) and TSH 2.5-4.5 mIU/L (n=45). The clinical data, hormonal profiles and reproductive outcomes were compared between groups. Additionally, a systematic review with meta-analysis following the PRISMA protocol was carried out in PubMed/MEDLINE, EMBASE, and SciELO, with no time or language restrictions, for articles comparing TSH groups named "low TSH" (<2,5 mIU/L) and "high TSH" (≥2.5 mIU/L). A meta-analysis of proportions was performed with pooled estimates expressed as relative risk (RR) of events and a random effects model.

RESULTS

Age, BMI, free thyroxine levels (FT4) hormonal profile and IVF outcomes were not different between groups, neither gestational outcomes (p=0.982). Also, no difference was observed when the TSH and FT4 levels were compared between patients with positive or negative gestational outcomes (p=0.27 and p=0.376). Regarding the systematic review with meta-analysis, 17 studies from 2006 to 2022 were included, and added by this original retrospective research comprising 13.247 women undergoing IVF. When comparing the proportions of clinical pregnancy between the TSH groups, no significant difference was found (RR 0.93, 95% CI 0.80-1.08), with high between studies heterogeneity (I²: 87%; τ²: 0.0544; p<0.01). The number of deliveries was not significantly different between groups, despite a trend towards higher frequency in the high-TSH group (RR 0.96, 95% CI 0.90-1.02).

CONCLUSION

Variation in TSH levels within the normal range was not associated with pregnancy and delivery rates in women, without autoimmune thyroid disease, who underwent IVF treatment.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD 42022306967.

Maternal essential metals, thyroid hormones, and fetal growth: Association and mediation analyses in Chinese pregnant women

BACKGROUND

Essential metals play critical roles in fetal growth and development, but results from human studies are inconsistent. Additionally, whether maternal thyroid hormone (TH) levels mediate the associations between essential metals and fetal growth remains unknown.

METHODS

Data for analysis were extracted from the Information System of Guangdong Women and Children Hospital between January 2017 and December 2019. Maternal levels of essential metals [copper (Cu), zinc (Zn), magnesium (Mg), and iron (Fe)] and THs were measured at the second trimester. Multivariate linear models were introduced to evaluate the potential associations between maternal essential metals, thyroid functions, and fetal growth, and the possible mediation effects of thyroid functions were explored in the median analyses.

RESULTS

A total of 4186 mother-infant pairs were included in the present study. Maternal Fe levels were found to significantly increase birth weight in 272.91 g (95 % CI: 15.59, 530.22) among anemia group. Maternal Cu levels were positively associated with increased free triiodothyronine/free thyroxine ratio (FT3/FT4). Negative associations of Fe and Mg levels with thyroid-stimulating hormone (TSH) concentrations were observed, accompanied with the positive associations in relation to FT3, FT4 and FT3/FT4 ratio. Mediation analyses suggested that 72.01 % of the associations between Fe levels and birth length might be mediated by FT3 levels. Additionally, 25.85 % of the Cu-birth length association and 44.53 % of the Fe-birth length association could be explained by FT3/FT4 ratio.

CONCLUSION

Our findings suggest that maternal Cu, Mg, and Fe levels can alter TH concentrations, and maternal FT3 and FT3/FT4 ratio might be potential mediators on the developmental effects of Cu and Fe levels.

Laboratory predictors of pregnancy in vitro fertilization

Identification of factors determining both of favorable and unfavorable outcome of IVF will increase the effectiveness of this method and optimize infertility treatment. The aim of the research is to analyze the correlation between serum IL-1α concentration, its gene rs1800587 (C/T) genotype carrier and thyroid-stimulating hormone (TSH), thyroid hormones (triiodothyronine (T3) and tetraiodothyronine (T4)), and evaluate the prognostic significance of their combinations in women with tube-peritoneal infertility under the IVF program. 120 patients with tube-peritoneal infertility who applied for an IVF program were examined. Depending on the outcome of the procedure, 2 groups of patients were allocated: 1 group - 40 women who had a pregnancy after IVF, 2 group - 80 patients who did not have a pregnancy. The content of IL-1α, TSH, T3, T4 was determined in blood by ELISA. Genotyping was performed on the rs1800587 (C/T) polymorphic marker of the IL-1α gene. TSH, T3, T4 were within the norm for both groups. In our study, women with a TSH concentration of 0.23 to 1.7 nmol/L had a chance of a favorable IVF outcome 1.4 times higher than with other TSH levels (p = 0.042901); with a T3 level of 1.0 to 1.8 nmol/L had a chance of becoming pregnant 5.7 times higher than with other levels of T3 (p = 0.00002). For T4 concentration, the confidence test was not achieved (p = 0.068505). The individual indicators of IL-1α, TSH, T3 and carrier of the genotype of the gene IL-1α at the preconceptive stage have lower diagnostic value than their combined combination. Three combinations have maximum predictive value: a combination of the T/T genotype of the IL-1α gene and the TSH level of 0.23 to 1.7 nmol/l - OR = 8.1 (p = 0.000048); combination of IL-1α of 28.7 to 85.1 pg/ml, T/T gene genotype IL-1α and TSH level of 0.23 to 1.7 nmol/l - OR = 8.1 (p = 0.000048); combination of IL-1α of 28.7 to 85.1 pg/ml, T/T gene genotype IL-1α, TSH level of 0.23 to 1.7 nmol/l and T3 level of 1.0 to 1.8 nmol/l - OR = 8.1 (p = 0.000146). Thus, proposed new prognostic markers of IVF program effectiveness.

Magnesium is a critical element for competent development of bovine embryos

The study was designed to determine the impact of magnesium (Mg²⁺) on bovine embryo development. We found that two commercially available sources of bovine serum albumin (BSA) and fetal bovine serum (FBS) contained different amounts of Mg²⁺ residue: 4 ppm in ICPbio BSA, 114 ppm in Sigma BSA, and 44 ppm in FBS. When CR1 was used as basal medium, PVA and ICPbio BSA produced the lowest blastocyst yield (2.2-2.3%), whereas Sigma BSA increased blastocyst yield to 18.9% (P < 0.05). Supplementation of 1.4 mM MgCl₂ into the medium increased the blastocyst rate in the ICPbio BSA group (29.4%) but not in the PVA group (5.4%; P < 0.05) to a level comparable to that of the FBS group (33.7%; P > 0.05). We next found that increasing concentrations of MgCl₂ in the culture medium (ICPbio BSA) elevated blastocyst rate from 2.6% (0 mM), 38.4% (0.35 mM) to 50.2% (1.4 mM; P < 0.05), further maintained at 44.9% (2.1 mM) and 43.4% (2.8 mM) (P > 0.05). However, blastocyst rate was reduced to 31.4% (4.2 mM) and 29.4% (5.6 mM) when MgCl₂ supplement was increased (P < 0.05). Comparable blastocyst development was achieved in both ICPbio BSA (30.0-33.1%) and Sigma BSA (37.4-38.7%) groups when 1.4 mM Mg²⁺ was supplemented regardless of its source (MgCl₂ vs. MgSO₄; P > 0.05). In embryo transfer experiments, higher rates of pregnancy (54.3 vs. 41.5%) and calving (44.3 vs. 32.5%) were achieved in the CR1-Mg²⁺-supplemented BSA group compared with the FBS group with co-culture, respectively (P < 0.05). These results demonstrate that Mg²⁺ is a key ion that promotes competent blastocyst and term development. Therefore, a simple and efficient defined medium (CR1-Mg²⁺-BSA) can successfully replace complex serum and somatic cell co-culture.

Micronutrient supplementation in pregnancy: Who, what and how much?

Pregnancy represents a period of major physiological and metabolic change, aiming to ensure proper fetal growth and development, as well as maternal preservation. This review focuses on maternal nutrition, and particularly on micronutrient deficiencies and supplementation during pregnancy. Nutrient deficiencies and consequences in pregnant women are presented, with an overview of current recommendations for dietary supplementation in pregnancy, even considering the risk of micronutrient overload. Appropriate universal supplementation and prophylaxis/treatment of nutritional needs currently appear to be the most cost-effective goal in low-income countries, thus ensuring adequate intake of key elements including folate, iron, calcium, vitamin D and A. In high-income countries, a proper nutritional assessment and counselling should be mandatory in obstetric care in order to normalize pregestational body mass index, choose a healthy dietary pattern and evaluate the risk of deficiencies.

A post-publication analysis of the idealized upper reference value of 2.5 mIU/L for TSH: Time to support the thyroid axis with magnesium and iron especially in the setting of reproduction medicine

Laboratory medicine approaches the evaluation of thyroid function mostly through the single determination of the blood level of thyroid stimulating hormone (TSH). Some authors have suggested an upper reference value for TSH of 2.5 mIU/L. This suggestion has not been confirmed by recent clinical studies. These studies have delivered a clinically valid reference range going from 0.3 to 3.5 mIU/L. These values are valid for both for the general population as well as in the setting of fertility and pregnancy. Current biochemical evidence about the elements required to maintain thyroid function shows that these not only include dietary iodine but also magnesium, iron, selenium and coenzyme Q10. Iron is important for the synthesis of thyroid peroxidase; magnesium-ATP contributes to the active process of iodine uptake; iodine has to be sufficiently present in the diet; selenium acts through selenoproteins to protect the thyroid cell during hormone synthesis and in deiodination of thyroxine; coenzyme Q10 influences thyroid vascularity. As a consequence, good clinical practice requires additional biochemical information on the blood levels of magnesium, selenium, coenzyme Q10 as well as iron status. Since these elements are also important for the maintenance of reproductive function, we postulate that they constitute the connecting link between both endocrine systems.

Applying a systems approach to thyroid physiology: Looking at the whole with a mitochondrial perspective instead of judging single TSH values or why we should know more about mitochondria to understand metabolism

Classical thinking in endocrine physiology squeezes our diagnostic handling into a simple negative feedback mechanism with a controller and a controlled variable. In the case of the thyroid this is reduced to TSH and fT3 and fT4, respectively. The setting of this tight notion has no free space for any additions. In this paper we want to challenge this model of limited application by proposing a construct based on a systems approach departing from two basic considerations. In first place since the majority of cases of thyroid disease develop and appear during life it has to be considered as an acquired condition. In the second place, our experience with the reversibility of morphological changes makes the autoimmune theory inconsistent.

While medical complexity can expand into the era of OMICS as well as into one where manipulations with the use of knock-outs and -ins are common in science, we have preferred to maintain a simple and practical approach. We will describe the interactions of iron, magnesium, zinc, selenium and coenzyme Q10 with the thyroid axis. The discourse will be then brought into the context of ovarian function, i.e. steroid hormone production. Finally the same elemental players will be presented in relation to the basic mitochondrial machinery that supports the endocrine.

We propose that an intact mitochondrial function can guard the normal endocrine function of both the thyroid as well as of the ovarian axis. The basic elements required for this function appear to be magnesium and iron. In the case of the thyroid, magnesium-ATP acts in iodine uptake and the heme protein peroxidase in thyroid hormone synthesis. A similar biochemical process is found in steroid synthesis with cholesterol uptake being the initial energy-dependent step and later the heme protein ferredoxin 1 which is required for steroid synthesis. Magnesium plays a central role in determining the clinical picture associated with thyroid disease and is also involved in maintaining fertility. With the aid of 3D sonography patients needing selenium and/or coenzyme Q10 can be easily identified. By this we firmly believe that physicians should know more about basic biochemistry and the way it fits into mitochondrial function in order to understand metabolism. Contemplating only TSH is highly reductionistic.

Outline

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Author's profiles and motivation for this analysis

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The philosophical alternatives in science and medicine

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Reductionism vs. systems approach in clinical thyroid disease guidelines

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The entry into complexity: the involvement of the musculoskeletal system

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Integrating East and West: teachings from Chinese Medicine and from evidence based medicine (EBM)

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Can a mathematical model represent complexity in the daily thyroid practice?

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How effective is thyroxine treatment?

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Resolving the situation of residual symptoms in treated patients with thyroid disease

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Importance of iron, zinc and magnesium in relation to thyroid function

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Putting together new concepts related to thyroid function for a systems approach

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Expanding our model into general aspects of medicine

Small for Gestational Age and Magnesium: Intrauterine magnesium deficiency may induce metabolic syndrome in later life

Magnesium deficiency during pregnancy as a result of insufficient or low intake of magnesium is common in developing and developed countries. Previous reports have shown that intracellular magnesium of cord blood platelets is lower among small for gestational age (SGA) groups than that of appropriate for gestational age (AGA) groups, suggesting that intrauterine magnesium deficiency may result in SGA. Additionally, the risk of adult-onset diseases such as insulin resistance syndrome is greater among children whose mothers were malnourished during pregnancy, and who consequently had a low birth weight. In a number of animal models, poor nutrition during pregnancy leads to offspring that exhibit pathophysiological changes similar to human diseases. The offspring of pregnant rats fed a magensium restricted diet have developed hypermethylation in the hepatic 11β-hydroxysteroid dehydrogenase-2 promoter. These findings indicate that maternal magnesium deficiencies during pregnancy influence regulation of non-imprinted genes by altering the epigenetic regulation of gene expression, thereby inducing different metabolic phenotypes. Magnesium deficiency during pregnancy may be responsible for not only maternal and fetal nutritional problems, but also lifelong consequences that affect the offspring throughout their life. Epidemiological, clinical, and basic research on the effects of magnesium deficiency now indicates underlying mechanisms, especially epigenetic processes.