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

Thyroid ultrasonic changes relate to implantation failure in euthyroid women with thyroid autoimmunity undergoing in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To determine whether ultrasonic manifestations of Hashimoto's thyroiditis (HT) related to embryo qualities or pregnancy outcomes in women with thyroid autoimmunity (TAI) undergoing in vitro fertilization/intracytoplasmic sperm injection.

METHODS

Our study was a retrospective cohort study. A total of 589 euthyroid women enrolled from January 2017 to December 2019. 214 TAI women and 375 control women were allocated in each group according to serum levels of thyroid peroxidase antibodies (TPOAb) and/or anti-thyroglobulin antibodies (TgAb). Basal serum hormone levels and thyroid ultrasound were assessed, embryo qualities, pregnancy outcomes were collected from medical records. Diagnosis of thyroid ultrasound was used for subanalysis. Logistic regression was used to evaluate outcomes of embryo development and pregnancy.

RESULTS

Implantation rate was significantly lower in euthyroid women with TAI compared with control group (TAI group: 65.5% vs. Control group: 73.0%, adjusted OR (95% CI): 0.65 (0.44, 0.97), p = 0.04). We further stratified TAI group into two groups: one group with HT features under ultrasound and another group with normal thyroid ultrasound. After regression analysis, TAI women with HT morphological changes had a lower chance of implantation compared with control group (TAI group with HT: 64.1% vs. Control group: 73.0%, adjusted OR (95% CI): 0.63 (0.41, 0.99), p = 0.04), while there was no significant difference on implantation rate between TAI women with normal thyroid ultrasound and control group. Other outcomes, such as embryo qualities and pregnancy rate, were comparable between TAI and control groups.

CONCLUSIONS

A higher risk of implantation failure was seen among euthyroid women with TAI, especially women with HT morphological changes under ultrasound. The underlying mechanisms of implantation failure among euthyroid HT patients need further research.

Impaired embryo development potential associated with thyroid autoimmunity in euthyroid infertile women with diminished ovarian reserve

Purpose

The aim of this study was to evaluate the associations of thyroid autoimmunity (TAI) with the number of oocytes retrieved (NOR), fertilization rate (FR), and embryo quality (EQ) in euthyroid women with infertility and diminished ovarian reserve (DOR).

Methods

This retrospective cohort study involved 1,172 euthyroid women aged 20-40 years with infertility and DOR who underwent an oocyte retrieval cycle. TAI was diagnosed in the presence of serum thyroperoxidase antibody (TPOAb) concentrations higher than 34 IU/ml and/or serum thyroglobulin antibody (TgAb) concentrations exceeding 115.0 IU/ml. Among these women, 147 patients with TAI were classified as the TAI-positive group, while 1,025 patients without TAI were classified as the TAI-negative group. Using generalized linear models (GLMs) adjusted for confounding factors, we evaluated the associations of TAI and the serum TPOAb and TgAb concentrations and NOR, FR, and EQ in this study's subjects. The TPOAb and TGAb values were subjected to log10 transformation to reduce skewness. Logistic regression models were used to estimate the effects of TPOAb and TgAb concentrations on the probabilities of achieving a high NOR (≥7) and high FR (>60%).

Results

For the whole study population, women with TAI had a significantly lower NOR and poorer EQ than women without TAI (P < 0.001 for both). Interestingly, in the TSH ≤2.5 subgroup, the TAI-positive group also had a significantly lower NOR and poorer EQ than the TAI-negative group (P < 0.001 for both). Furthermore, negative associations were observed between log10(TPOAb) concentrations and NOR and the number of high-quality embryos and available embryos (P < 0.05 for all). The log10(TgAb) concentrations were inversely associated with NOR and the number of high-quality embryos (P < 0.05 for all). In the regression analysis, the log10(TPOAb) concentrations had lower probabilities of achieving a high NOR [adjusted odds ratio (aOR): 0.56; 95% confidence interval (95% CI) 0.37, 0.85; P = 0.007].

Conclusions

TAI and higher TPOAb and TgAb concentrations were shown to be associated with reductions in the NOR and EQ in the study population. Our findings provide further evidence to support systematic screening and treatment for TAI in euthyroid women with infertility and DOR.

Acupuncture Combined with Bushen-Jianpi Decoction Ameliorates the Ovarian Function of Diminished Ovarian Reserve Rats by Regulating Phosphoinositide 3-Kinase/AKT Signaling

OBJECTIVE

This study aimed to explore the therapeutic efficiency as well as mechanism of acupuncture combined with Bushen-Jianpi decoction (BJD) to treat rats with diminished ovarian reserve (DOR).

METHODS

A DOR rat model was constructed using zona pellucida 3 peptide, and acupuncture, BJD, and their combination were administered as therapeutic interventions. We measured changes in the ovarian indexes, the number of follicles at all levels, the serum levels of sex hormones and immune factors, the expression levels of phosphoinositide 3-kinase (PI3K), AKT, p-AKT, and caspase-3, and the changes in the proportions of splenic T cell subtypes, including T-helper 17 (Th17), Tc17, regulatory T (Treg), CD4+, and CD8+ cells.

RESULTS

Acupuncture combined with BJD induced a decrease in the levels of follicle-stimulating and luteinizing hormones, and the effect was greater than that elicited by BJD or acupuncture alone (P < 0.05). Additionally, this combination treatment effectively abrogated the increase in the levels of interleukin-2 (IL-2), IL-17, anti-zona pellucida antibody, and cleaved caspase-3 (P < 0.05), while promoting the regulation of IL-6 and p-AKT (P < 0.01). Furthermore, treatment with acupuncture combined with BJD restored the proportions of CD4+ cells and the CD4+ / CD8+ T cell ratio (P < 0.01), decreased the proportion of CD8+ T and Th17 cells (P < 0.01), and increased the proportions of Tc17 and Treg cells (P < 0.01).

CONCLUSION

Combining acupuncture with BJD can enhance ovarian function in DOR rats. The regulation of sex hormone levels and immune function in rats may be attributed to the adjustment of the mRNA and proteins levels of PI3K, AKT, and caspase-3 in the PI3K/AKT signaling pathway, which leads to an improvement in the immune function of DOR rats.

Comparisons of conventional in vitro fertilization versus intracytoplasmic sperm injection in women with thyroid autoimmunity and non-male factor infertility, a propensity score matching analysis

The aim of the study is to compare the outcomes between the insemination methods of conventional in vitro fertilization and intracytoplasmic sperm injection in infertile women with thyroid autoimmunity and non-male factor infertility. This was a retrospective cohort study which included women with thyroid autoimmunity and non-male factor infertility. Reproductive outcomes such as embryo development parameters and clinical outcomes were compared between the two groups. The propensity score matching was applied to balance the general characteristics with significant differences between the two groups. Generalized estimating equations were used to explore the impact of ICSI on the embryo development potential of the inseminated oocytes. Sensitivity analysis using E-values was used to account for unknown confounders. After 1:2 propensity score matching, the general characteristics were all comparable. The good cleavage embryo rate, blastocyst utilization rate, and good blastocyst rate were significantly lower in the intracytoplasmic sperm injection group than those in the conventional in vitro fertilization group. After controlling for the confounding factors, intracytoplasmic sperm injection was significantly negatively associated with development of usable blastocysts and good blastocysts, while showed no impact on fertilized oocytes, usable cleavage embryos and good cleavage embryos. Although limited by the limited sample size, there were comparable clinical and obstetrical outcomes between conventional in vitro fertilization and intracytoplasmic sperm injection groups. Intracytoplasmic sperm injection neither improved the embryo development potential nor increased the clinical pregnancy and live birth rates compared to conventional in vitro fertilization in the studied population. Prospective studies that randomly divide the studied population in two the two groups and compare the reproductive outcomes are warranted.

Impact of thyroid autoimmunity on pregnancy outcomes in euthyroid patients with recurrent implantation failure

RESEARCH QUESTION

Does thyroid autoimmunity (TAI) adversely affect pregnancy outcomes after IVF/intracytoplasmic sperm injection (ICSI) in euthyroid patients with recurrent implantation failure (RIF)?

DESIGN

This retrospective cohort study was conducted at the Reproductive Hospital Affiliated with Shandong University from November 2016 to September 2021. A total of 1031 euthyroid patients diagnosed with RIF were enrolled. Based on serum thyroid autoantibody concentrations, the participants were divided into two groups: the TAI-positive group (219 women with RIF) and the TAI-negative group (812 women with RIF). The parameters were compared between the two groups. Additionally, logistic regression was used to adjust related confounders for primary outcomes, and subgroup and stratified analyses were performed according to different thyroid autoantibody types and TSH concentrations.

RESULTS

There was no significant difference in ovarian reserve, ovarian response, embryo quality, pregnancy outcome or neonatal outcome between the two groups (P > 0.05). After adjustments for age, body mass index, thyroid-stimulating hormone and free thyroxine, the biochemical pregnancy rate in the TAI-positive group was significantly lower than that in the TAI-negative group (odds ratio 1.394, 95% CI 1.023-1.901, adjusted P = 0.036). Regarding the implantation rate, clinical pregnancy rate, pregnancy loss rate, stillbirth rate and live birth rate, no significant differences were observed even with subgroup and stratified analyses (P > 0.05).

CONCLUSIONS

TAI had no impact on pregnancy outcomes in euthyroid RIF patients who underwent IVF/ICSI. In clinical practice, interventions targeting thyroid autoantibodies in these patients should be implemented with caution and additional evidence is needed.

Maternal preconception thyroid autoimmunity is associated with neonatal birth weight conceived by PCOS women undergoing their first in vitro fertilization/intracytoplasmic sperm injection

BACKGROUND

Thyroid autoimmunity and polycystic ovary syndrome (PCOS) are the most common endocrinopathies and have close relationships based on common etiology and pathogenesis, including genetic susceptibility, metabolic disorders, hormonal dysregulation, immune response, and inflammatory activation. The co-occurrence of both diseases is associated with adverse reproductive outcomes, but its effect on neonatal outcomes remains largely unknown. We aim to explore the effect of thyroid autoimmunity on neonatal birth weight in PCOS women undergoing IVF/ICSI.

METHODS

This is a retrospective analysis of 486 PCOS women who underwent the first IVF/ICSI cycles and gave birth to 361 singletons and 125 twins during 2018 - 2020 at a reproductive center. The associations between maternal preconception serum thyroid function and autoimmunity indicators and birth weights of the singleton and twin groups were evaluated using generalized linear models (GLMs) and generalized estimate equations (GEEs), respectively. Analyses were further stratified by neonatal sex, maternal age, and maternal preconception BMI to assess the possible interaction effects.

RESULTS

Maternal preconception serum TPOAb had a significant negative association with singleton birth weight (P for trends = 0.03). Compared with women in the first tertile of TPOAb, women in the third tertile had a change in singleton birth weight of - 119.72 g (95% CI: - 222.68 g, - 16.70 g). Maternal preconception serum TPOAb had a significant positive association with twin birth weight (P for trends = 0.01). Compared with women in the first tertile of TPOAb, women in the third tertile had a change in twin birth weight of 138.62 g (95% CI: 33.96 g, 243.30 g). Besides, maternal preconception serum TPOAb had a specific association with increased twin birth weight for female neonates, a specific association with decreased singleton birth weight for PCOS women under 35 years, and a specific association with decreased twin birth weight for overweight PCOS women (all P for interactions < 0.05).

CONCLUSIONS

Maternal preconception thyroid autoimmunity may affect the birth weights of both singleton and twin neonates. Further large cohorts and experimental studies are required to confirm these findings and explore the underlying mechanisms.

Relationship between thyroid antibody levels and ovarian reserve function in infertile chinese women with normal thyroid-stimulating hormone

BACKGROUND

To analyze the relationship of thyroid peroxidase antibody and thyroid globulin antibody levels with ovarian reserve function in infertile women.

METHODS

The data of 721 infertile patients who visited the hospital from January 2019 to September 2022 and whose thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) levels were in the normal range, were retrospectively analyzed. These patients were divided into two sets of three groups-the negative group, the 2.6 IU/ml ~ 100 IU/ml group and the TPOAb > 100 IU/ml group according to the TPOAb (thyroid peroxidase antibody) level, or the TgAb (anti-thyroglobulin antibody) negative group, the 14.58 IU/ml ~ 100 IU/ml group and the TgAb > 100 IU/ml group according to the TgAb level. They were compared for differences in ovarian reserve function index and thyroid hormone levels and analyzed for the relationship among thyroid antibody levels, ovarian reserve function, and thyroid hormone levels.

RESULTS

When TSH > 2.5 mIU/L, the bFSH (basal follicle stimulating hormone) level in the TPOAb > 100 IU/ml group (9.10 ± 1.16 IU/L) was significantly higher than that in the TPOAb negative group (8.12 ± 1.97 IU/L) and the 2.6 IU/ml ~ 100 IU/ml group (7.90 ± 1.48 IU/L) (P < 0.05); when TSH ≤ 2.5 mIU/L, there were no statistically significant differences in the bFSH and AFC (antral follicle count) number at different TPOAb levels. Whether TSH ≤ 2.5 mIU/L or TSH > 2.5 mIU/L, there were no statistically significant differences in the bFSH and AFC number at different TgAb levels (P > 0.05). FT3/FT4 ratio in the TPOAb 2.6 IU/ml ~ 100 IU/ml group and the > 100 IU/ml group was significantly lower than in the negative group. FT3/FT4 ratio in the TgAb 14.58 ~ 100 IU/ml group and the > 100 IU/ml group was also significantly lower than in the TgAb negative group (P < 0.05). TSH level in the TPOAb > 100 IU/ml group was significantly higher than in the 2.6 ~ 100 IU/ml group and the TPOAb negative group, but there were no statistically significant differences among different TgAb groups.

CONCLUSIONS

When TPOAb > 100 IU/ml and TSH > 2.5 mIU/L, it may affect the ovarian reserve function in infertile patients, and the mechanism may be associated with increased TSH and the imbalance of FT3/FT4 ratio caused by the increase of TPOAb.

Impact of thyroid autoimmunity on pregnancy outcomes in euthyroid women following fresh/frozen-thawed embryo transfer

OBJECTIVE

To investigate whether thyroid autoimmunity (TAI) is associated with assisted reproductive technology (ART) outcomes in euthyroid women undergoing fresh embryo transfer (ET) and frozen-thawed embryo transfer (FET).

DESIGN

A retrospective cohort study. Pregnancy and neonatal outcome after fresh ET or FET were compared between the positive and negative thyroid autoimmune antibody groups.

PATIENTS

A total of 5439 euthyroid women who started their ART cycle at our centre between 2015 and 2019 were included.

RESULTS

The thyroid antibody positive group had a greater mean age than the thyroid antibody negative group (32(29,35) vs. 31(28,34), p < .001). Women with positive thyroid antibody presented with a higher prevalence of diminished ovarian reserve (DOR) (9.1% vs. 7.1%, p = .026) and lower number of oocyte retrieved (9(5,15) vs. 10(6,15), p = .020), but difference was not significant after adjusting for age. The pregnancy rate, live birth rate, pregnancy loss rate, preterm delivery rate and low birthweight rate between the thyroid antibody positive and thyroid antibody negative groups were comparable both in fresh ET cycles and FET cycles. Subanalysis of the treatment outcomes when using a stricter threshold of TSH of 2.5 mIU/L showed no difference to that achieved when using an upper limit of 4.78 mIU/L.

CONCLUSIONS

The present study reveals that patients with anti-thyroid peroxidase antibodies (TPOAbs) and/or antithyroglobulin antibodies (TgAbs) showed no significant differences in pregnancy outcomes following fresh ET and FET when compared with patients with negative thyroid antibodies.

Thyroid Autoimmunity Is Not Associated with Embryo Quality or Pregnancy Outcomes in Euthyroid Women Undergoing Assisted Reproductive Technology in China

Background: Studies have shown that thyroid autoimmunity (TAI) is associated with increased risks of adverse pregnancy outcomes. The aim of this study was to investigate the associations between TAI and embryo quality in euthyroid women undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI). Methods: This retrospective cohort study included euthyroid infertile women with and without TAI (defined as a serum thyroperoxidase concentration ≥34 IU/mL or a thyroglobulin concentration ≥115.0 IU/mL) who underwent their first complete IVF/ICSI treatment cycles at a tertiary referral center between April 2016 and February 2022. Embryo quality measurements and clinical outcomes were compared between women with (TAI positive) and without TAI (TAI negative). The high-quality cleavage embryo rate and cumulative live birth rate (cLBR) were the primary outcomes. Results: A total of 499 TAI-positive and 2945 TAI-negative women were included in this study, and their mean (standard deviation) ages were 31.6 (4.5) and 30.9 (4.4) years, respectively (p = 0.001). The overall analysis showed no significant differences between TAI-negative and TAI-positive women in the high-quality cleavage embryo rate (n/N: 11,139/22,553 vs. 1971/3820; adjusted rate: 52.8% vs. 53.4%, p = 0.66) and cLBR (1917/2945 vs. 327/499; 53.4% vs. 56.2%, p = 0.31). Moreover, no significant differences were observed between TAI-negative and TAI-positive women in the rates of oocyte retrieval (35,078/51,978 vs. 5853/8628; 69.1% vs. 69.4%; p = 0.65), fertilization (23,067/34,197 vs. 3902/5728; 61.1% vs. 62.2%, p = 0.34), embryo utilization (18,233/22,553 vs. 3156/3820; 80.2% vs. 80.8%, p = 0.61), blastocyst formation (7051/13,721 vs. 1192/2330; 48.5% vs. 48.4%, p = 0.97), and high-quality blastocysts (4819/13,721 vs. 799/2330; 29.9% vs. 29.4%, p = 0.73). Furthermore, no significant differences were observed between TAI-negative and TAI-positive women in the clinical pregnancy rate (1524/2808 vs. 248/482; 46.7% vs. 44.6%, p = 0.40), early pregnancy loss rate (156/1524 vs. 23/248; 13.5% vs. 11.5%, p = 0.44), and LBR (1338/2808 vs. 218/482; 37.4% vs. 36.0%, p = 0.55) of the first transfer cycle. Conclusions: This study demonstrated that TAI in women was not associated with embryo quality or the cLBR following IVF/ICSI. Future large studies are warranted to confirm these findings.

Comparison of reproductive outcomes in subclinical hypothyroidism women with high-normal versus low-normal thyroid-stimulating hormone levels after treatment with levothyroxine

OBJECTIVE

Reproductive outcomes in euthyroid women with high-normal thyroid-stimulating hormone (TSH) levels are comparable to those in euthyroid women with low TSH levels; however, few studies have investigated whether strictly controlled TSH levels after levothyroxine (LT4) treatment impair reproductive outcomes in infertile women with subclinical hypothyroidism (SCH). This study aimed to investigate the impact of high-normal versus low-normal TSH levels on reproductive outcomes in women undergoing their first in vitro fertilisation and embryo transfer (IVF-ET) cycle.

DESIGN

This was a retrospective cohort study. Patients were divided into low-normal (TSH < 2.5 mIU/L, and ≥0.27 mIU/L) and high-normal (TSH ≥ 2.5 mIU/L, and <4.2 mIU/L) groups based on TSH levels after LT4 treatment. TSH levels after LT4 treatment and before ovarian stimulation were recorded. Reproductive outcomes were compared between the low-normal and high-normal TSH groups and between the euthyroid and LT4-treated groups.

RESULTS

A total of 6002 women, 548 of whom were LT4-treated women, were finally included in this study. Among the LT4-treated women, 129 women had low-normal TSH levels, and 167 women had high-normal TSH levels. The clinical pregnancy rate, miscarriage rate, and live birth rate were comparable between the low-normal and high-normal groups (all p > .05). When adjusted by age, anti-Mullerian hormone (AMH) levels, infertility duration, transferred embryos, and dose and duration of LT4 treatment, high-normal TSH levels neither significantly decreased miscarriage (adjusted odds ratio [aOR] = 2.27, 95% confidence interval [CI] = 0.77-6.69, p = .14) nor increased clinical pregnancy (aOR = 1.15, 95% CI = 0.70-1.89, p = .57 or live birth (aOR = 0.97, 95% CI = 0.60-1.59, p = .92). Similar obstetric outcomes were observed between the low-normal and high-normal TSH groups after LT4 treatment and between the euthyroid and LT4-treated groups (all p ≥ .05).

CONCLUSIONS

High-normal TSH levels did not have adverse effects on clinical and obstetric outcomes when compared with low-normal TSH levels after LT4 treatment. However, whether it is appropriate to set 2.5 mIU/L as the goal of treatment before IVF/ICSI remains to be determined in further well-designed studies.

Impact of Thyroid Autoimmunity on Assisted Reproductive Technology Outcomes and Ovarian Reserve Markers: An Updated Systematic Review and Meta-Analysis

Background: Thyroid autoimmunity (TAI) has a high prevalence among women of reproductive age. Investigating its possible impact on ovarian function and fertility is, thus, of utmost relevance. The aim of this systematic review and meta-analysis was to elucidate the effect of TAI on both assisted reproductive technology (ART) outcomes and ovarian reserve. Methods: This systematic review and meta-analysis was restricted to two groups of research articles investigating the association between TAI and: (1) autologous ART outcomes (i.e., fertilization rate [FR], implantation rate, clinical pregnancy rate [CPR], miscarriage rate, and live birth rate), (2) markers of ovarian reserve (i.e., anti-Müllerian hormone, basal follicle stimulating hormone, antral follicle count, and number of oocytes retrieved). Studies including women affected by overt hypo/hyperthyroidism were excluded. Relevant studies were identified by a systematic search in PubMed, MEDLINE, ClinicalTrials.gov, Embase, and Scopus, from database inception to May 1, 2022. Results: From a total of 432 identified publications, 22 studies were included in Group 1 and 26 studies in Group 2. The presence of TAI was associated with a higher risk of miscarriage (7606 participants, odds ratio [OR] 1.52, confidence interval [CI 1.14-2.01], p = 0.004, I² = 53%), lower chance of embryo implantation (7118 participants, OR 0.72, [CI 0.59-0.88], p = 0.001, I² = 36%), and live birth (11417 participants, OR 0.73, [CI 0.56-0.94], p = 0.02, I² = 71%). These associations were no longer observed in a subgroup analysis of patients who exclusively underwent intracytoplasmic sperm injection (ICSI). The FR and CPR as well as the mean values of surrogate markers of oocyte quantity appeared not to be affected by TAI. Conclusions: This data synthesis suggest a higher risk of adverse ART outcomes in women with positive TAI. However, the reliability of these findings is hampered by the relatively low quality of the evidence and significant heterogeneity in many of the meta-analyses. The possible protective effect of ICSI is promising but should be confirmed in controlled prospective clinical trials. PROSPERO Registration ID: CRD42021236529.

The Impact of Moderately High Preconception Thyrotropin Levels on Ovarian Reserve Among Euthyroid Infertile Women Undergoing Assisted Reproductive Technology

Background: Thyroid dysfunction is prevalent in reproductive-age women and has been identified as a risk factor for female infertility. However, it remains largely unclear whether subtle thyroid dysfunction, as estimated by moderately high thyrotropin (TSH) levels within the normal range, is associated with ovarian reserve in infertile women before assisted reproductive technology (ART) treatment. Methods: This cross-sectional study involved 3501 euthyroid infertile women, including 2189 women with TSH levels ≤2.5 μIU/mL and 1312 women with high-normal TSH levels (2.51-4.20 μIU/mL). Ovarian reserve markers were compared between women with low- and high-normal TSH levels. Correlation analysis and regression models were used to estimate the association of TSH levels with ovarian reserve. In addition, the association of subtle thyroid dysfunction with ovarian reserve was further evaluated after stratification for different infertility diagnoses and statuses of thyroid autoimmunity (TAI). Results: In the total population, women with high-normal TSH levels had significantly decreased anti-Müllerian hormone (AMH) concentrations (p < 0.001), a lower bilateral antral follicle count (AFC) (p < 0.001), and a higher prevalence of diminished ovarian reserve (DOR) (p = 0.018) than women with low-normal TSH levels. The TSH levels showed a negative association with both AMH levels (r = -0.050, p = 0.003) and bilateral AFC (r = -0.071, p < 0.001). Furthermore, the association of high-normal TSH levels with decreased AMH and AFC was more prominent in infertile women with ovulation dysfunction (p = 0.002, p = 0.002), unexplained infertility (p = 0.020, p = 0.028), or negative TAI (both p < 0.001). Conclusions: These data suggested that subtle thyroid dysfunction was associated with DOR in infertile women before ART treatment, which will add evidence that strengthens the systematic screening of TSH levels/TAI in infertile women and will contribute to the discussion of specific TSH cutoff values in predicting ovarian reserve.

Effect of hypothyroidism and thyroid autoimmunity on the ovarian reserve: A systematic review and meta-analysis

Background

Evidence suggests that hypothyroidism and thyroid autoimmunity (TAI) are possibly associated with ovarian dysfunction. This meta‐analysis aimed to investigate whether hypothyroidism and/or TAI affect the ovarian reserve and evaluated using the anti‐Mullerian hormone (AMH).

Methods

PubMed, EMBASE, Web of Science, and Cochrane Controlled Trials Register databases from inception to October 2020 were searched to identify relevant studies. Studies comparing the AMH levels between the control and the affected groups were included in the data synthesis. The primary endpoint in the meta‐analysis was AMH levels compared with the controls.

Main findings

Nine trials were included in the analysis. The AMH levels were significantly lower in the adults with euthyroid TAI (mean difference −0.12, [95% CI: −0.18 to −0.06]). The AMH levels tended to be lower in subclinical hypothyroidism and overt hypothyroidism than in the control group, although the differences were not significant. The AMH levels were significantly higher in the euthyroid TAI group in the adolescents (mean difference 2.51, [95% CI 1.82 to 3.21]).

Conclusion

TAI and hypothyroidism may affect the ovarian reserve. The opposite effects on AMH levels depending on age suggest that TAI may be implicated in the depletion of follicles in adults following extensive activation of primordial follicles in adolescence.

Preimplantation genetic testing is not a preferred recommendation for patients with X chromosome abnormalities

STUDY QUESTION

Should women with X chromosome abnormalities (XCAs) be recommended to have embryos selected by both morphological and cytogenetic assessment through preimplantation genetic testing (PGT) rather than morphological assessment only in conventional IVF/ICSI treatment?

SUMMARY ANSWER

PGT is not a preferred recommendation for women with XCAs in the absence of other PGT indications.

WHAT IS KNOWN ALREADY

XCAs are the most frequent sort of chromosomal aberrations in infertile women. Patients with a complete or partial absence of one X chromosome, diagnosed as Turner Syndrome (TS), demonstrate low spontaneous pregnancy rates (5-7%) and high miscarriage rates (22.8-30.8%), as well as high chances of birth defects (20%). PGT is known to improve pregnancy rates and decrease the incidence of miscarriage in couples with chromosomal aberrations such as Robertsonian and reciprocal translocations and Klinefelter Syndrome.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was conducted with 394 women with XCAs and undergoing their first oocyte retrieval and first embryo transfer cycle from June 2011 to August 2019 in the Reproductive Hospital Affiliated to Shandong University.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pregnancy outcomes were compared between the conventional IVF/ICSI group (n = 284) and the PGT group (n = 110) in the first fresh or frozen embryo transfer cycle for each woman with XCAs. Three platforms were applied in PGT: fluorescence in situ hybridisation (FISH, n = 34), array comparative genomic hybridisation (aCGH, n = 24) and next-generation sequencing (NGS, n = 51). The embryo aneuploidy rate and distribution of embryonic chromosomal aberrations revealed by aCGH or NGS were analysed and stratified by maternal age and type of XCAs to assess the effect of maternal XCAs on embryo karyotypes.

MAIN RESULT AND THE ROLE OF CHANCE

The live birth rate (LBR) per embryo transfer was similar between the PGT group and IVF/ICSI group both in the first cycle of fresh or frozen embryo transfer respectively (39.13% in PGTFISH vs 42.58% in IVF/ICSI, Padj=0.558; 66.67% in PGTFISH vs 52.08% in PGTaCGH/NGS vs 53.06% in IVF/ICSI, Padj=0.756), as was the clinical pregnancy rate (60.87% in PGTFISH vs 50.97% in IVF/ICSI, Padj =0.672; 88.89% in PGTFISH vs 58.33% in PGTaCGH/NGS vs 69.39% in IVF/ICSI, Padj =0.480) and the pregnancy loss rate (35.71% in PGTFISH vs 16.46% in IVF/ICSI, Padj =0.136; 12.50% in PGTFISH vs 10.71% in PGTaCGH/NGS vs 23.53% in IVF/ICSI, Padj =0.352). The rates of maternal and neonatal complications were also comparable between the PGT and IVF/ICSI groups with fresh and frozen transfers respectively (10.00% vs 8.85%, P = 1.000; 21.74% vs 14.55%, P = 0.272). Intriguingly, the distribution of embryonic chromosome abnormalities was more frequent on autosomes 22 (20.39%), 21 (18.45%) and 16 (17.47%), compared with the X chromosome (8.73%).

LIMITATIONS, REASONS FOR CAUTION

Selection bias is an inherent drawback of a retrospective study. First, our participants hosted 4.84% X chromosome mosaicism with few typical somatic anomalies of TS. Second, the incidences of history of recurrent miscarriage and abnormal offspring in the PGT group were higher than in IVF/ICSI group although binary logistic regression analysis was performed to attenuate the modifying effect of confounding factors. Third, FISH performed in this study only used X/Y probes and lacked the reference of autosome, which might have resulted in misdiagnosis and bias. Finally, intrinsic disadvantages could not be totally avoided due to the retrospective nature of this study.

WIDER IMPLICATION OF THE FINDINGS

In the current study, comparable pregnancy outcomes were revealed among a large cohort of women with XCAs undergoing their first cycles of PGT or conventional IVF/ICSI treatment. Moreover, the X chromosome abnormality was illustrated to cause no higher frequency of aberrations in embryos. Our data provided perspectives for genetic and reproductive counselling to XCAs individuals and their families.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by National Research and Development Plan (2016YFC1000604 and 2017YFC1001100), the National Natural Science Foundation of China (81701406), Shandong Science Fund for Distinguished Young Scholars (JQ201720), Taishan Scholars Program for Young Experts of Shandong Province (tsqn20161069) and Projects of Medical and Health Technology Development Program in Shandong Province (202005010520, 202005010523 and 2016WS0368). There is no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Thyroid autoimmunity is associated with higher risk of premature ovarian insufficiency-a nationwide Health Insurance Research Database study

STUDY QUESTION

Is thyroid autoimmunity associated with a higher risk of low ovarian reserve and POI?

SUMMARY ANSWER

Thyroid autoimmunity significantly increases the risk of POI in women.

WHAT IS KNOWN ALREADY

POI is closely related with autoimmune disease, and according to some studies, thyroid autoimmunity (TAI) may account for diminished ovarian reserve. However, no large-scale cohort study has demonstrated the association between TAI and POI.

STUDY DESIGN, SIZE, DURATION

A longitudinal population-based retrospective cohort study on the National Health Insurance Research Database (NHIRD) was designed. Since 1 March 1995, the National Health Insurance (NHI) programme in Taiwan has included 99.9% of the 23 million population of Taiwan. Patients between 1 January 2000 and 31 December 2012 were eligible for recruitment, and 21 325 subjects were analysed in our study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two cohorts, Hashimoto's and Grave's disease, were composed of patients with autoimmune thyroid disease between 20 and 40 years of age. The comparison cohorts consisted of patients in the NHIRD without autoimmune thyroid disease matched by age at a ratio of 1:4 in subject numbers.

MAIN RESULTS AND THE ROLE OF CHANCE

The Hashimoto's disease (HD) cohort, Grave's disease (GD) cohort and two comparison cohorts were followed up until a diagnosis of amenorrhoea, menopausal syndrome, other ovarian failure or infertility due to ovarian failure had been made. Compared statistically with the non-HD cohort, patients with HD exhibited an 89% higher risk of amenorrhoea (95% CI =1.36-2.61). The HD patients exhibited a 2.40-fold higher risk of infertility due to ovarian failure than the non-HD subjects (hazard ratio (HR)=2.40, 95% confidence interval (CI)=1.02-5.68). In comparison with the non-GD cohort, patients with GD exhibited a 68% higher risk of amenorrhoea (95% CI = 1.43-1.98) after adjustment. According to the Kaplan-Meier analysis, the cumulative incidence of amenorrhoea and menopausal syndrome was significantly higher in the TAI groups than in the control groups.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study using ICD-9 disease code analysis to determine the statistical association between two diseases.

WIDER IMPLICATIONS OF THE FINDINGS

Given that autoimmune thyroid disease is highly associated with early diminished ovarian reserve or even premature ovarian failure or POI, the options for infertility treatment may be re-directed to more efficient methods in infertile patients diagnosed with the disease. If the ovarian reserve is normal at the time of diagnosis of thyroid autoimmune disease, close follow-up of ovarian reserve may be highly recommended.

STUDY FUNDING/COMPETING INTEREST(S)

This study is supported in part by Taiwan Ministry of Health and Welfare Clinical Trial Center, Grant Number: MOHW109-TDU-B-212-114004. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Association between thyroid autoimmunity and ovarian reserve in women with hypothyroidism

Background

The ovarian function and therefore the ovarian reserve may be compromised by the pathogenesis of autoimmune diseases of which, Hashimoto’s thyroiditis (HT) is the most common in women of reproductive age. Furthermore, a prolonged reduction in thyroid hormone concentration results in a broad spectrum of reproductive alteration. Previous reports in the literature have been controversial regarding the impact of hypothyroidism and alterations in the ovarian reserve. Thus, this prospective and comparative study aimed to evaluate the association of hypothyroidism with low ovarian reserve.

Materials and Methods

A subset of 27 patients with primary autoimmune hypothyroidism were compared to healthy women. The ovarian reserve was assessed through the anti-Mullerian hormone (AMH) and the antral follicle count (AFC).

Results

Overall, the two groups did not display significant differences in length of their menstrual cycles neither in the AMH serum levels nor the AFC.

Conclusions

No significant alteration was found in the ovarian reserve of women with HT.

Correlation Analysis Between Ovarian Reserve and Thyroid Hormone Levels in Infertile Women of Reproductive Age

OBJECTIVE

To analyze the correlation between ovarian reserve and thyroid function in women with infertility.

METHODS

Retrospective analysis of the data of 496 infertility patients who visited the clinic between January 2019 and December 2020. According to the TSH level, it is grouped into <2.5 mIU/L, 2.5~4.0mIU/L and ≥4.0 mIU/L or according to the positive/negative thyroid autoimmune antibody. The relationship was assessed through the ovarian reserve, thyroid function, and anti-Müllerian hormone (AMH) levels in infertile patients. On the other hand, the patients are divided into groups according to age (≤29 years old, 30-34 years old and ≥35 years old), basic FSH (<10 IU/L and ≥10 IU/L), and AMH levels. The ovarian reserve was evaluated through the AMH and the antral follicle count (AFC).

RESULTS

The average age of the patients was 30.31 ± 4.50 years old, and the average AMH level was 5.13 ± 4.30 ng/mL. 3.63% (18/496) of patients had abnormal TSH levels (normal: 0.35-5.5 mIU/L), the positive rate of thyroid peroxidase antibody (TPOAb) was 14.52% (72/496), the positive rate of anti-thyroglobulin antibody (TgAb) was 16.94% (84/496), and the positive rate of TPOAb and TgAb was 10.48% (52/496). After grouping according to TSH level or thyroid autoimmune antibody positive/negative grouping, the analysis found that there was no statistical significance in age, AMH level and basic FSH level among the groups (P>0.05). There were no significant differences in the levels of TSH, FT3, and FT4 among different ages, AMH, and FSH levels (P>0.05).

CONCLUSION

There is no significant correlation between ovarian reserve and thyroid function in infertile women.

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.