Thyroid autoimmunity, infertility and miscarriage

The Role of Cell and Gene Therapies in the Treatment of Infertility in Patients with Thyroid Autoimmunity

There is a rising incidence of infertility worldwide, and many couples experience difficulties conceiving nowadays. Thyroid autoimmunity (TAI) is recognized as one of the major female infertility causes related to a diminished ovarian reserve and potentially impaired oocyte maturation and embryo development, causing adverse pregnancy outcomes. Growing evidence has highlighted its impact on spontaneously achieved pregnancy and pregnancy achieved by in vitro fertilization. Despite the influence of thyroid hormones on the male reproductive system, there is insufficient data on the association between TAI and male infertility. In past years, significant progress has been achieved in cell and gene therapies as emerging treatment options for infertility. Cell therapies utilize living cells to restore healthy tissue microenvironment and homeostasis and usually involve platelet-rich plasma and various stem cells. Using stem cells as therapeutic agents has many advantages, including simple sampling, abundant sources, poor immunogenicity, and elimination of ethical concerns. Mesenchymal Stem Cells (MSCs) represent a heterogeneous fraction of self-renewal, multipotent non-hematopoietic stem cells that display profound immunomodulatory and immunosuppressive features and promising therapeutic effects. Infertility has a genetic component in about half of all cases, although most of its genetic causes are still unknown. Hence, it is essential to identify genes involved in meiosis, DNA repair, ovarian development, steroidogenesis, and folliculogenesis, as well as those involved in spermatogenesis in order to develop potential gene therapies for infertility. Despite advances in therapy approaches such as biological agents, autoimmune disorders remain impossible to cure. Recent research demonstrates the remarkable therapeutic effectiveness of MSCs in a wide array of autoimmune diseases. TAI is one of many autoimmune disorders that can benefit from the use of MSCs, which can be derived from bone marrow and adipose tissue. Cell and gene therapies hold great potential for treating autoimmune conditions, although further research is still needed.

Antithyroid antibodies may predict serum beta HCG levels and biochemical pregnancy losses in euthyroid women with IVF single embryo transfer

OBJECTIVE

To investigate the relationship between thyroid autoimmunity and early pregnancy serum β-HCG levels in intracytoplasmic sperm injection patients.

METHODS

The study subjects were 85 female euthyroid patients undergoing intracytoplasmic sperm injection embryo transfer cycles with GnRH antagonist treatment. Patients who received transfer of more than one embryo, those with serum TSH levels of greater than 2.5 IU/ml and subjects using levothyroxine were excluded. Normal responder patients under the age of 40 years were randomly selected from the patient files retrospectively. Subjects were divided into two groups: those with autoimmune thyroid disease (thyroid autoimmunity group; n = 39) and those without the disease (control group; n = 46).

RESULTS

The age, body mass index, trial number, total rFSH treatment dose, the number of cumulus oophorus complexes, number of metaphase II oocytes, and number of 2-pronuclei embryos were similar in the thyroid autoimmunity and control groups. Serum β-HCG levels measured on the 14th day after oocyte pickup were significantly lower in the thyroid autoimmunity group than in the control group (93.8 ± 35.8 versus 128.5 ± 55.8 mlU/ml, respectively; p < .001). The miscarriage rate was higher in the thyroid autoimmunity group than in the control group (34.4% versus 21.7%, respectively; p = .034).

CONCLUSION

We found that early-stage pregnancy serum β-HCG hormone levels among euthyroid patients undergoing intracytoplasmic sperm injection were lower in subjects with thyroid autoimmunity than in those without thyroid autoimmunity. This result, reported for the first time in the literature on euthyroid pregnant women with thyroid autoimmunity, may be predictor of early pregnancy losses in pregnant women with thyroid autoimmunity.Key messageIn intracytoplasmic sperm injection (ICSI)/IVF patients, due to lack of evidence-based data about the relationship between thyroid autoimmunity and pregnancy loss the current research was conducted. Early-stage pregnancy serum β-HCG hormone levels in euthyroid ICSI patients with thyroid autoimmunity are lower than those without autoimmunity which may be associated with early pregnancy losses.

Impact of Thyroid Autoimmunity in euthyroid women on the outcomes of In Vitro Fertilization

OBJECTIVE

Infertility is inadequately acknowledged as a problem in developing countries. Thyroid Autoimmunity (TAI) has been neatly investigated for its association with unfavorable pregnancy and reproductive consequences. We aim to evaluate Clinical Pregnancy Rate (CPR) as a primary outcome following In Vitro Fertilization/Intra Cytoplasmic Sperm Injection (IVF/ICSI) in women with Thyroid Autoimmunity (TAI).

METHODS

A Retrospective cohort study included 584 women who underwent IVF/ICSI treatment between November 2012 and April 2017 in Orient Hospital, Damascus, Syria. Patients were tested for TAI before IVF/ICSI procedure.

RESULTS

CPR did not significantly differ between TAI positive and TAI negative groups (p > 0.05). Subgroup analysis for only primary infertility patients showed a statistically significant difference in CPR between TAI positive and TAI negative groups.

CONCLUSION

Although several arguments were in favor of the relation between IVF/ICSI outcomes and Thyroid autoimmune disease, the presence of TAI positivity did not adversely affect the clinical pregnancy rate.

Infertility in women with systemic autoimmune diseases

Infertility consists by definition in" failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse" while the term subfertility means a delay to achieve pregnancy. Several factors can contribute to infertility or subfertility in patients with systemic autoimmune diseases. The association of systemic autoimmune conditions with endometriosis, celiac disease and thyroid autoimmunity that are well known causes of infertility and/or subfertility need to be taken in consideration when difficulties in the onset of pregnancy is reported. The majority of the used antirheumatic drugs do not interfere with fertility. However, the use of cyclophosphamide, limited to severe disease, can provoke premature ovarian failure; to preserve fertility a preventive treatment is available. Nonsteroidal anti-inflammatory drugs can cause temporary infertility and corticosteroids are associated to a prolonged time to pregnancy in some rheumatic diseases. Data on the association of antiphospholipid antibodies (aPL) with infertility are still debated but in general an increased rate of aPL is described patients undergoing medically assisted reproductive techniques. In systemic lupus erythematosus aPL and other autoantibodies (i.e. anti-oocytes) can contribute to the infertility of some patients. Subfertility, rather than infertility, is observed in patients with rheumatoid arthritis; the particular physical conditions of these women can also account for this. Physicians should not forget the patients' age, that is mandatory in order to preserve their chance to have children.

[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.

Prevalence of Thyroid Autoimmune Antibodies in Women Seeking Fertility Care in Damascus, Syria

Introduction

Thyroid autoimmune (TAI) disease with a prevalence varying between 5 and 15%, represents the most common endocrine disorder in women with reproductive age. Not only is TAI disease five to 10 folds more common in women than men but also TAI diseases is often undiagnosed because it may be present without overt thyroid dysfunction for several years. Studies found an increased prevalence of TAI in women referred to fertility clinics compared with normal population. In this analysis we aimed to study the prevalence of TAI among women seeking fertility care in Damascus, Syria in order to understand its clinical and public health importance in population.

Methods

This study is a retrospective cross-sectional study on women patients seeking fertility care at Orient Hospital, Damascus city, Syria from April 2011 to March 2018. A total of 2526 women, with available biochemical data of anti-thyroid antibodies (anti-TPO) and anti-thyroglobulin antibodies (anti-TG) were included in our study. Thyroid stimulating hormone (TSH) titers data were also included in the statistical analysis.

Results

TAI was found positive in 559 patients (22.1%) of our studies population. TAI was more prevalent in patients with abnormal TSH levels.

Conclusion

Thyroid autoimmunity prevalence in women seeking fertility care in Damascus, Syria was 22.1% which is significantly higher than normal population. Further studies are needed to assess the relation of these antibodies in thyroid, gynecological and other factors for the Syrian population.

Effects of levothyroxine treatment on pregnancy outcomes in pregnant women with autoimmune thyroid disease

BACKGROUND

Despite some studies indicating that thyroid antibody positivity during pregnancy has been associated with adverse pregnancy outcomes, evidence regarding the effects of levothyroxine (LT4) treatment of euthyroid/subclinical hypothyroid pregnant women with autoimmune thyroid disease on pregnancy outcome is limited. We aimed to assess whether pregnant women with autoimmune thyroid disease, but without overt thyroid dysfunction are affected by higher rates of adverse pregnancy outcomes. In addition, we aimed to explore whether LT4 treatment improves the pregnancy outcome of affected women.

METHODS

A prospective study was carried out on pregnant women from the first trimester to delivery. The study was conducted among pregnant women receiving prenatal care in centers under coverage of Shahid Beheshti University of Medical Sciences. Of a total of 1746 pregnant women, screened for thyroid dysfunction, 1028 euthyroid TPOAb-negative (TPOAb^-) and 131 thyroid peroxidase antibody-positive (TPOAb⁺) women without overt thyroid dysfunction entered the second phase of the study. TPOAb⁺ women were randomly divided into two groups: group A (n = 65), treated with LT4 and group B (n = 66), received no treatment. The 1028 TPOAb^- women (group C) served as a normal population control group. Primary outcomes were preterm delivery and miscarriage and secondary outcomes included placenta abruption, still birth, neonatal admission and neonatal TSH levels.

RESULTS

Groups A and C displayed a lower rate of preterm deliveries compared with group B (RR = 0.30, 95% CI: 0.1-0.85, P = 0.0229) and (RR = 0.23, 95% CI: 0.14-0.40, P < 0.001) respectively. There was no statistically significant difference in the rates of preterm labor between groups A and C (RR = 0.79, 95% CI: 0.30-2.09, P = 0.64). The number needed to treat (NNT) for preterm birth was 5.9 (95% CI: 3.33–25.16).

CONCLUSIONS

Treatment with LT4 decreases the risk of preterm delivery in women who are positive for TPOAb.

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.

Anti-Müllerian hormone as a marker of premature ovarian aging in autoimmune thyroid disease

There is an increased incidence of autoimmune thyroid disease (AITD) in women with infertility. We hypothesized that serum anti-Müllerian hormone (AMH) levels will be lower in premenopausal women with AITD than controls. We evaluated ovarian reserve in women with AITD (n = 85) and healthy controls (n = 80), all <40 years old. Detailed data on reproductive history were obtained. Gonadotrophins, steroids, AMH, and inhibin B levels were measured during the follicular phase. The number of pregnancies as well as live births was lower in women with AITD (p < 0.01). No difference was observed in terms of FSH, estradiol, and inhibin B. AMH levels were lower in AITD women than in controls (1.16 + 0.17 versus 1.28 + 0.25 ng/ml, mean + SD, p = 0.001). According to the multiple regression analysis, even after age adjustment, AITD was significantly and independently affected AMH levels (t = 2.674, p = 0.008). Women with AITD seem to have a diminished ovarian follicular reserve and measurement of serum AMH level has the potential to be used to predict this comorbidity.

Thyroid diseases during pregnancy: a number of important issues

The most common thyroid diseases during pregnancy are hyper- and hypothyroidism and their variants including isolated hypothyroxinemia (hypo-T4), autoimmune thyroid disease (AITD) and different types of goiter. AITD represents the main cause of hypothyroidism during pregnancy ranging in prevalence between 5 and 20% with an average of 7.8%. The incidence of isolated hypo-T4 is about 150 times higher compared to congenital hypothyroidism. Prevalence of Graves' disease (GD) ranges between 0.1% and 1% and the Transient Gestational Hyperthyroidism Syndrome between 1 and 3%. Thyroid stimulating hormone (TSH) is a sensitive marker of thyroid dysfunction during pregnancy. Normal values have been modified recently with a downward shift. Thus, the upper normal range is now considered to be 2.5 mUI/mL in the first trimester and 3.0 mUI/mL for the remainder of pregnancy. Most studies have shown that children born to women with hypothyroidism during gestation had significantly lower scores in neuropsychological tests related to intelligence, attention, language, reading ability, school performance and visual motor performance. However, some studies have not confirmed these findings. On the other hand, multiple retrospective studies have shown that the risks of maternal and fetal/neonatal complications are directly related to the duration and inadequate control of maternal thyrotoxicosis. The latter is associated with a risk of spontaneous abortion, congestive heart failure, thyrotoxic storm, preeclampsia, preterm delivery, low birth weight and stillbirth. Despite the lack of consensus among professional organizations, recent studies, which are based on sophisticated analyses, support universal screening in all pregnant women in the first trimester for thyroid diseases.

Female reproduction physiology adversely manipulated by thyroid disorders: a review of literature

Proper thyroid function is vital to have a healthy reproduction system. Female sex hormones are altered due to hypothyroidism and hyperthyroidism. Female reproduction system is negatively manipulated by both hyperthyroidism and hypothyroidism and menstrual disorders are the ultimate consequences. Hypomenorrhea, polymenorrhea and oligomenorrhea are the clinical manifestation associated with hyperthyroidism and hypothyroidism, respectively. The female infertility is also adversely affected by thyrotoxicosis and myxedema, the clinical presentation of hyper and hypothyroidism. The simultaneous existence of autoimmunity which is present among some portion of pregnant women may aggravate the clinical manifestation of thyroid disorders in female reproductive physiology. Abortion, premature infants, low birth infant, are among clinical presentation of overt hypothyroidism. Auto antibody against thyroid stimulating hormone receptor and eventual hyperthyroidism considered as risk factors which require extra attention while the thyroid disorder is clinically managed during pregnancy to prevent the fetus from abnormal metabolism. The aim of this review is to elaborate the adverse role of hyperthyroidism and hypothyroidism in female reproduction physiology.

Thyroid function and human reproductive health

Via its interaction in several pathways, normal thyroid function is important to maintain normal reproduction. In both genders, changes in SHBG and sex steroids are a consistent feature associated with hyper- and hypothyroidism and were already reported many years ago. Male reproduction is adversely affected by both thyrotoxicosis and hypothyroidism. Erectile abnormalities have been reported. Thyrotoxicosis induces abnormalities in sperm motility, whereas hypothyroidism is associated with abnormalities in sperm morphology; the latter normalize when euthyroidism is reached. In females, thyrotoxicosis and hypothyroidism can cause menstrual disturbances. Thyrotoxicosis is associated mainly with hypomenorrhea and polymenorrhea, whereas hypothyroidism is associated mainly with oligomenorrhea. Thyroid dysfunction has also been linked to reduced fertility. Controlled ovarian hyperstimulation leads to important increases in estradiol, which in turn may have an adverse effect on thyroid hormones and TSH. When autoimmune thyroid disease is present, the impact of controlled ovarian hyperstimulation may become more severe, depending on preexisting thyroid abnormalities. Autoimmune thyroid disease is present in 5-20% of unselected pregnant women. Isolated hypothyroxinemia has been described in approximately 2% of pregnancies, without serum TSH elevation and in the absence of thyroid autoantibodies. Overt hypothyroidism has been associated with increased rates of spontaneous abortion, premature delivery and/or low birth weight, fetal distress in labor, and perhaps gestation-induced hypertension and placental abruption. The links between such obstetrical complications and subclinical hypothyroidism are less evident. Thyrotoxicosis during pregnancy is due to Graves' disease and gestational transient thyrotoxicosis. All antithyroid drugs cross the placenta and may potentially affect fetal thyroid function.