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

Effect and mechanism of Hashimoto thyroiditis on female infertility: A clinical trial, bioinformatics analysis, and experiments-based study

Diagnosing Hashimoto thyroiditis (HT) relies on thyroglobulin antibody (TgAb) and thyroid peroxidase antibody (TPOAb) titers. The influence of these antibodies on female infertility remains a subject of debate. This study aims to explore the effect and mechanism of HT on female infertility. First, a single-center cross-sectional study was conducted to investigate whether TgAb and TPOAb are the key factors leading to female infertility. Second, bioinformatic analysis was performed to investigate the potential target molecules and pathways. Third, in vivo experiments were performed to explore the effects of elevated TgAb levels on embryo implantation in a mouse model of autoimmune thyroiditis (AIT). Four hundred and five infertile women and 155 healthy controls were enrolled in the cross-sectional study. Results indicated that the TPOAb titer was associated with female infertility, while the TgAb titer showed no significant association. The increased levels of TgAb and TPOAb are not significantly correlated with anti-Mullerian hormone. Bioinformatic analysis indicated that the common target molecules for HT and female infertility include interleukin (IL)-6, IL-10, matrix metalloproteinase 9, and tumor necrosis factor, suggesting potential regulation through multiple signaling pathways such as HIF-1, VEGF, MAPK, and Th17 cell differentiation. A certain dose of porcine thyroglobulin can successfully establish a mouse model of AIT. In this mouse model, embryo implantation and ovarian reserve remain unaffected by elevated TgAb levels. In conclusion, the serum TPOAb titer was associated with infertility due to female factors but the TgAb titer showed no significant association. A simple increase in serum TgAb titer does not affect embryo implantation and ovarian reserve in the AIT model.

Evaluation of a large set of patients with Autoimmune Polyglandular Syndrome from a single reference centre in context of different classifications

PURPOSE

To characterize patients with APS and to propose a new approach for their follow-up. Query ID="Q1" Text="Please check the given names and familynames."

METHODS

Monocentric observational retrospective study enrolling patients referred to the Outpatients clinic of the Units of Endocrinology, Diabetology, Gastroenterology, Rheumatology and Clinical Immunology of our Hospital for Autoimmune diseases.

RESULTS

Among 9852 patients, 1174 (11.9%) [869 (73.9%) female] were diagnosed with APS. In 254 subjects, the diagnosis was made at first clinical evaluation (Group 1), all the other patients were diagnosed with a mean latency of 11.3 ± 10.6 years (Group 2). Group 1 and 2 were comparable for age at diagnosis (35.7 ± 16.3 vs. 40.4 ± 16.6 yrs, p = .698), but different in male/female ratio (81/173 vs 226/696, p = .019). In Group 2, 50% of patients developed the syndrome within 8 years of follow-up. A significant difference was found after subdividing the first clinical manifestation into the different outpatient clinic to which they referred (8.7 ± 8.0 vs. 13.4 ± 11.6 vs. 19.8 ± 8.7 vs. 7.4 ± 8.1 for endocrine, diabetic, rheumatologic, and gastroenterological diseases, respectively, p < .001).

CONCLUSIONS

We described a large series of patients affected by APS according to splitters and lumpers. We propose a flowchart tailored for each specialist outpatient clinic taking care of the patients. Finally, we recommend regular reproductive system assessment due to the non-negligible risk of developing premature ovarian failure.

Elevated Thyroglobulin Antibody Level is Associated with Decreased Anti-Müllerian Hormone in Women of Reproductive Age

Purpose

Women with Hashimoto's thyroiditis (HT) have an increased risk of ovarian insufficiency. However, whether thyroid antibodies affect the ovarian reserve remains controversial. The aim of this study was to explore the possible relationship between anti-Müllerian hormone (AMH) and thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb) levels in women of reproductive age.

Methods

A total of 483 women between 18 and 45 years old who had their TPOAb, TgAb, thyroid-stimulating hormone (TSH), free thyroxine (FT4), and AMH levels measured on the same day were enrolled in this study. The levels of TSH, FT4, TPOAb, and TgAb, the prevalence of overt and subclinical hypothyroidism, and the positive rate of TPOAb and TgAb were compared between patients with low (below the 10th percentile), normal (10th to 90th percentile), and high (higher than the 90th percentile) AMH levels.

Results

The median AMH level was 1.72 (0.33-4.27) ng/mL. A total of 9.9% of patients had low AMH levels. The TgAb levels and the prevalence of TgAb positivity were higher in the low AMH group (37.62 (13.10-232.68) IU/mL, 35.42%) than in the normal (12.46 (10.0-67.04) IU/mL, 19.59%) and high (13.61 (10.0-95.74) IU/mL, 23.4%) AMH groups (p=0.001, p=0.040, respectively). Serum AMH levels were inversely correlated with TgAb levels (r = -0.114, p=0.013).

Conclusion

The AMH of women of reproductive age is affected by HT. Furthermore, women with the lowest AMH level had higher levels of TgAb and a positive rate of TgAb, and high TgAb levels may cause autoimmune damage to the ovaries.

A review of autoimmunity and immune profiles in patients with primary ovarian insufficiency

Primary ovarian insufficiency (POI) is a complicated clinical syndrome characterized by progressive deterioration of ovarian function. Autoimmunity is one of the main pathogenic factors affecting approximately 10% to 55% of POI cases. This review mainly focuses on the role of autoimmunity in the pathophysiology of POI and the potential therapies for autoimmunity-related POI. This review concluded that various markers of ovarian reserve, principally anti-Müllerian hormone, could be negatively affected by autoimmune diseases. The presence of lymphocytic oophoritis, anti-ovarian autoantibodies, and concurrent autoimmune diseases, are the main characteristics of autoimmune POI. T lymphocytes play the most important role in the immune pathogenesis of POI, followed by disorders of other immune cells and the imbalance between pro-inflammatory and anti-inflammatory cytokines. A comprehensive understanding of immune characteristics of patients with autoimmune POI and the underlying mechanisms is essential for novel approaches of treatment and intervention for autoimmune POI.

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.

Thyroid autoimmunity and reproduction: Bidirectional relationship that continues to intrigue

Today, infertility is not only a serious health but also a psycho-social problem, one that is on the rise in the world. Thyroid autoimmunity (TAI) is the most common disease of the thyroid gland in the reproductive period, which can affect spontaneous conception as well as conception through assisted reproduction technology (ART), but also the maintenance of healthy pregnancy. It can also cause numerous maternal and fetal complications. There is a wide array of publications on the topic of the mechanisms of association between TAI and reproduction, with the question of whether thyroid autoantibodies are solely tissue-specific antibodies, whether and when to start levothyroxine treatment, and that we require more fundamental research on the direct effect of thyroid autoantibodies starting from folliculogenesis to embryogenesis and implantation as well as the post-implantation embryo development, but also the composition of the follicular fluid as a microenvironment of enormous importance for the maturation of the oocytes which thyroid autoantibodies reach via the blood-follicle barrier.

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.

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.

Evaluation of serum anti-Müllerian hormone levels in women with Hashimoto thyroiditis in the reproductive age

Background/aim

Autoimmune thyroid disease in women is associated with subfertility and early pregnancy loss, and patients with primary ovarian insufficiency have a high prevalence of thyroid autoimmune disorders. The aim of this study was to investigate the association between Hashimoto thyroiditis (HT) and ovarian reserve.

Materials and methods

Levels of serum thyroid stimulating hormones, thyroid autoantibodies, and anti-Müllerian hormone (AMH) were measured in women with HT and a healthy control group between 2018 and 2019.

Results

Evaluation was made of 108 premenopausal women with HT, and a control group of 172 healthy females with normal antithyroid antibody levels and thyroid function. Serum AMH levels were determined to be significantly lower in the HT group compared to the control group.

Conclusion

Ovarian reserve evaluated by serum AMH concentration is affected by thyroid autoimmunity independently of antithyroid antibodies type or titers.

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.

Hashimoto's thyroiditis worsens ovaries in polycystic ovary syndrome patients compared to Anti-Müllerian hormone levels

BACKGROUND

The human ovary is the target of autoimmune attack in cases of autoimmune disorders, which can cause ovarian dysfunction. Due to the higher prevalence of Hashimoto's Thyroiditis (HT) in Polycystic Ovary Syndrome (PCOS) patients, we aimed to evaluate ovarian reserve and the effect of autoimmune exposure time on ovarian reserve in PCOS patients with HT by Anti-Müllerian hormone (AMH) levels.

METHODS

Forty-six PCOS patients and 46 PCOS with HT diagnosed patients who are between 18 and 35 years old were recruited for this study. Detailed medical histories were obtained from all participants. Polycystic ovary image was evaluated and antral follicles were counted by transvaginal ultrasound. Modified Ferriman Gallwey score, body mass index, waist/hip ratio of the patients were examined. Hormonal, biochemical profiles and AMH levels of the patients were evaluated during the early follicular phase. The data of both groups were statistically analyzed with SPSS 18.0.

RESULTS

20 (43.5%) patients in the PCOS group were fertile, 8 (17.4%) patients in the PCOS + HT group were fertile, fertility rate was significantly lower in PCOS + HT group. The mean AMH value was 8.8 ± 8.8 in the PCOS + HT group and 12.4 ± 8.1 in the PCOS group and it was significantly lower in the PCOS + HT group (p = 0.043). AMH values were significantly negatively correlated with anti-thyroid peroxidase antibody (anti-TPO) level and the duration of HT. There was a significant positive correlation between the anti-TPO level and the duration of HT. CONCLUSıON: We pointed out that the coexistence of PCOS and HT, two prevalent diseases of reproductive age, further diminished ovarian reserve. More exposure of the ovaries to autoantibodies can cause ovarian destruction, similar to the thyroid gland like HT. Because of all these close relations with PCOS and thyroid dysfunctions, we recommend evaluating both thyroid autoantibodies and hormone levels in PCOS patients at the first visit. Patients with PCOS + HT should be monitored more closely to determine the fertility treatment options and control premature ovarian failure (POF) table.

Autoimmune Diseases in Patients with Premature Ovarian Insufficiency-Our Current State of Knowledge

Premature ovarian insufficiency (POI), previously known as premature ovarian failure or premature menopause, is defined as loss of ovarian function before the age of 40 years. The risk of POI before the age of 40 is 1%. Clinical symptoms develop as a result of estrogen deficiency and may include amenorrhea, oligomenorrhea, vasomotor instability (hot flushes, night sweats), sleep disturbances, vulvovaginal atrophy, altered urinary frequency, dyspareunia, low libido, and lack of energy. Most causes of POI remain undefined, however, it is estimated that anywhere from 4-30% of cases are autoimmune in origin. As the ovaries are a common target for autoimmune attacks, an autoimmune etiology of POI should always be considered, especially in the presence of anti-oocyte antibodies (AOAs), autoimmune diseases, or lymphocytic oophoritis in biopsy. POI can occur in isolation, but is often associated with other autoimmune conditions. Concordant thyroid disorders such as hypothyroidism, Hashimoto thyroiditis, and Grave's disease are most commonly seen. Adrenal autoimmune disorders are the second most common disorders associated with POI. Among women with diabetes mellitus, POI develops in roughly 2.5%. Additionally, autoimmune-related POI can also present as part of autoimmune polyglandular syndrome (APS), a condition in which autoimmune activity causes specific endocrine organ damage. In its most common presentation (type-3), APS is associated with Hashomoto's type thyroid antibodies and has a prevalence of 10-40%. 21OH-Antibodies in Addison's disease (AD) can develop in association to APS-2.

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.

Women with Autoimmune Thyroiditis have Lower Reproductive Life Span or Not? A Cross- Sectional Study

Background:

Autoimmune diseases are a main cause of primary ovarian insufficiency. This study was designed to elucidate the relationship between ovarian reserve and anti-thyroid peroxidase antibodies in women of different ages.

Methods:

98 women in a cross-sectional study was conducted at the infertility Center of Shiraz University of Medical Sciences, Hazrate Zeinab Hospital, from September 2018 to March 2019. Women with infertility and thyroid-stimulating hormone (TSH) &gt; 3mIU/L were included in the study with convenience sampling. Data were collected by a form containing demographic characteristics, thyroid hormones, and ovarian reserve data. Participants were categorized based on the negative or positive anti-thyroid peroxidase (anti-TPO) antibodies. According to a pilot sample, and possible dropout of 20%, the sample size was determined to be 49 cases in each group. The results were compared between groups using SPSS, version 22. All statistical comparisons were performed using the t-test, and the data are presented as the mean±SD. P-values less than 0.05 were considered significant.

Results:

49 women were analyzed in each group. There was no significant difference between the groups in the mean age (P=0.42), body mass index (BMI) (P=0.34), duration of infertility (P=0.99), mean prolactin (P=0.66), TSH (P=0.17), thyroxine (T4) (P=0.87) and follicle-stimulating hormone (FSH) levels (P=0.14). Ovarian reserve characteristics: antral follicular count (AFC) and anti-Müllerian hormone (AMH) levels in anti-TPO positive group were 10.61±7.29 and 1.98±2.38, respectively, and AFC and AMH in anti- TPO negative group were 16.46±6.38 and 2.94±2.22, respectively. There were significant differences between the two groups on AFC (P <0.001) and AMH (P=0.04).

Conclusion:

Patients with autoimmune thyroiditis were at higher risk for decreased ovarian reserve. They should consider their lower reproductive life span during their childbearing years.

Adalimumab Increases Follicle Reserve and Follicle Development in Rat Ovary: The Effect of Adalimumab on Ovarian Reserve

Introduction

Adalimumab is used in the treatment of many chronic inflammatory diseases, especially rheumatoid arthritis. The aim of this experimental study is to determine the histological and biochemical effects of adalimumab on rat ovary.

Methods

Wistar albino female rats were randomly divided into three groups prior to the experiment: a healthy control group, a 2 mg/kg adalimumab group, and a 5 mg/kg adalimumab group. Then, histopathological findings and biochemical examinations were made in the ovaries of the rats. Hematoxylin-eosin staining, morphometric examination, and Masson trichrome staining were performed. Antimullerian hormone (AMH) levels were measured in the biochemical examination.

Results

Ovarian follicle count and AMH level were significantly higher in the groups given low-dose adalimumab and high-dose adalimumab (p <0.001). In addition, fibrosis decreased in proportion to the dose of adalimumab (p <0.001).

Conclusion

Adalimumab is an important biological agent that contributes to the preservation of ovarian function by increasing ovarian follicle reserve and has shown that it can help preserve ovarian reserve in women of reproductive age suffering from chronic inflammatory diseases.

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 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.

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.

Reduced Ovarian Function in Female Rheumatoid Arthritis Patients Trying to Conceive

OBJECTIVE

Subfertility, a time to pregnancy (TTP) longer than 12 months, is present in 40% of female patients with rheumatoid arthritis (RA) who are actively trying to conceive. Because patients with RA appear to reach menopause at a younger age, diminished ovarian function may explain the reduced fertility. Serum anti-Müllerian hormone (AMH) levels are the best proxy to measure ovarian function. Our objectives were to study AMH levels in female patients with RA and determine the association of preconception serum AMH levels with TTP.

METHODS

A post hoc analysis was performed before conception in patients of the Pregnancy-Induced Amelioration of Rheumatoid Arthritis (PARA) cohort. Serum AMH levels were compared with those in an existing cohort of healthy controls using analysis of covariance. Associations between AMH and TTP were studied using the Cox proportional hazard analysis.

RESULTS

Preconception serum was available in 209 women of the PARA cohort (aged 32.1 ± 3.9 years), of whom 45% were subfertile in the current episode. The median AMH level was 2.5 μg/l (interquartile range: 1.5-4.6). AMH levels were significantly lower compared with those in healthy controls (P < 0.001), with 17% of patients having levels below the age-specific 10th percentile. A multivariable analysis showed a negative association of AMH with the presence of anticitrullinated protein antibodies (ACPAs) (P = 0.009). AMH levels showed no significant association with TTP (P = 0.26).

CONCLUSION

Women with RA have lower AMH levels than healthy controls, and AMH levels were lower in ACPA-positive patients. However, because preconception AMH levels were not associated with TTP, the reduced AMH levels do not explain the reduced fertility in patients with RA.

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.

Thyroid Hormone Deiodination and Action in the Gonads

Alterations in thyroid hormone (TH) status during developmental or adult age are associated with abnormal gonadal development and function in human and animal models. In the developing testis, aberrant levels of TH action lead to disruptions in cell proliferation and differentiation, ultimately influencing testicular size, spermatogenesis, steroidogenesis and male fertility. Recent work is increasingly identifying the systems and signaling pathways in gonadal cells that are affected by TH, as well as delineating the major factors that determine TH signaling in gonadal tissue. The TH receptor alpha, the monocarboxylate transporter 8 and the type 3 deiodinase appear to be major contributors to the timely regulation of TH action in the developing testis.

Evaluation of ovarian reserve in women with overt or subclinical hypothyroidism

INTRODUCTION

Thyroid dysfunction is among the most common autoimmune disorders in women of reproductive age. Previous studies have shown the association between autoimmune thyroid disease (AITD) and infertility. Anti-Müllerian hormone (AMH) is secreted by granulosa cells and is a useful marker for assessment of ovarian reserve. In the present study, we sought to evaluate the ovarian reserves of women with autoimmune thyroid disorder by measurement of AMH values.

MATERIAL AND METHODS

This prospective study included women with newly diagnosed AITD aged between 20 and 40 years. Patients were divided into three groups: subclinical hypothyroidism (SCH, n = 21), overt hypothyroidism (OH, n = 21) and controls (CG, n = 32). Study parameters included serum free T4, free T3, thyroid-stimulating hormone, anti-thyroglobulin, anti-thyroid peroxidase antibodies, follicle-stimulating hormone, luteinizing hormone, estradiol and AMH concentrations measured in the early follicular phase. Antral follicle count (AFC) was assessed with ultrasound. Body mass index (BMI) and waist circumference of the patients were noted.

RESULTS

No significant difference was found among SCH, OH and CG in regard to ovarian reserves measured by AMH values (p = 0.19) and AFC (p = 0.80). A significant negative correlation was found between AMH and BMI (r = -0.382, p = 0.001). Anti-Müllerian hormone and waist circumference (r = -0.330, p = 0.004) were also negatively correlated.

CONCLUSIONS

Although AMH values were not significantly different among groups, AMH values were lower in OH and SCH patients, indicating a possible need for close monitoring of these patients.

Age at natural menopause in women on long-term methotrexate therapy for rheumatoid arthritis

OBJECTIVE

The aim of the study was to compare the natural menopause ages of healthy women with those of women with methotrexate (MTX)-treated rheumatoid arthritis (RA), and to specifically assess the effect of disease onset and activity and the use of MTX on the age of the last menstruation.

METHODS

We performed a retrospective review of medical records to identify the ages at which menopause occurred in women with premenopausal RA treated with MTX and in women with postmenopausal onset, irrespective of therapy. Natural menopause ages were also compared between participants with and without RA.

RESULTS

Women with premenopausal onset of RA underwent menopause at a significantly younger age than did healthy women (P < 0.001) or those with postmenopausal disease onset (P = 0.001). Menopause also occurred at younger ages in participants with postmenopausal disease onset than in healthy controls (P = 0.012). The study suggested that menopause age was positively correlated with the age at which RA was diagnosed (R = 0.51; P < 0.001) in women with premenopausal RA onset, but was independent of the participant's age at menarche, number of pregnancies, or MTX therapy. Participants with RA onset at ≤ 35 years of age had a ninefold higher risk of premature menopause (P = 0.008).

CONCLUSIONS

The age at which menopause occurs in a patient with RA depends on the patient's age at the time of disease onset and its duration, but is not influenced by MTX treatment.

Natural history of autoimmune primary ovarian insufficiency in patients with Addison's disease: from normal ovarian function to overt ovarian dysfunction

CONTEXT

Women with autoimmune Addison's disease with normal ovulatory cycles but positive for steroid cell antibodies (StCA) have been considered at risk of premature ovarian insufficiency (POI).

DESIGN

Thirty-three women younger than 40 years, with subclinical-clinical autoimmune Addison's disease but with normally ovulatory menses, were followed up for 10 years to evaluate the long-term time-related variations of StCA, ovarian function and follicular reserve. All patients and 27 control women were investigated at the start and every year for the presence and titre of StCA (by indirect immunofluorescence), serum concentrations of anti-Mullerian hormone (AMH) and ovarian function at four consecutive menses every year.

RESULTS

At the start of the study StCA were present in 16 women (group 1), at low/middle titres (≤1:32) in seven of them (43.8%, group 1A), at high titres (>1:32) in the remaining nine patients (group 1B, 56.2%), while they were absent from 17 patients (group 2). During the follow-up period, all women in group 1A remained StCA-positive at low/middle titres with normal ovulatory menses and normal gonadotrophin and AMH levels, while all patients in group 1B showed a further increase of StCA titres (1:128-1:256) and progressed through three stages of ovarian function. None of the patients in group 2 and controls showed the appearance of StCA or ovarian dysfunction during the follow-up.

CONCLUSIONS

The presence of StCA at high titres can be considered a good predictive marker of subsequent development of autoimmune POI. To single out the stages of autoimmune POI may allow a timely therapeutic choice in the subclinical and early clinical stages.

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.

Prolonged hypothyroidism severely reduces ovarian follicular reserve in adult rats

Background

There is substantial evidence both in humans and in animals that a prolonged reduction in plasma thyroid hormone concentration leads to reproductive problems, including disturbed folliculogenesis, impaired ovulation and fertilization rates, miscarriage and pregnancy complications. The objective of the present study is to examine the consequences of chronic hypothyroidism, induced in adulthood, for the size of the ovarian follicle pool. In order to investigate this, adult female rats were provided either a control or an iodide deficient diet in combination with perchlorate supplementation to inhibit iodide uptake by the thyroid. Sixteen weeks later animals were sacrificed. Blood was collected for hormone analyses and ovaries were evaluated histologically.

Results

At the time of sacrifice, plasma thyroid-stimulating hormone concentrations were 20- to 40-fold increased, thyroxine concentrations were negligible while tri-iothyronin concentrations were decreased by 40% in the hypothyroid group, confirming that the animals were hypothyroid. Primordial, primary and preantral follicle numbers were significantly lower in the hypothyroid ovaries compared to the euthyroid controls, while a downward trend in antral follicle and corpora lutea numbers was observed. Surprisingly the percentage of atretic follicles was not significantly different between the two groups, suggesting that the reduced preantral and antral follicle numbers were presumably not the consequence of increased degeneration of these follicle types in the hypothyroid group. Plasma anti-Müllerian hormone (AMH) levels showed a significant correlation with the growing follicle population represented by the total ovarian number of primary, preantral and antral follicles, suggesting that also under hypothyroid conditions AMH can serve as a surrogate marker to assess the growing ovarian follicle population.

Conclusions

The induction of a chronic hypothyroid condition in adult female rats negatively affects the ovarian follicular reserve and the size of the growing follicle population, which may impact fertility.

What affects functional ovarian reserve, thyroid function or thyroid autoimmunity?

BACKGROUND

Thyroid dysfunction is the most common autoimmune endocrine disorder in women of reproductive age, and is associated with menstrual irregularities, anovulation and infertility. Whether it is thyroid function or thyroid autoimmunity that affects functional ovarian reserve (FOR, i.e., the small growing ovarian follicle pool) reflected in anti-Müllerian hormone (AMH) has, however, remained under dispute.

METHODS

We investigated in 225 infertile women whether thyroid function, after adjustment for thyroid autoimmunity, affects FOR within what is considered normal thyroid function (TSH, 0.4-4.5μIU/mL) by assessing AMH levels in reference to TSH levels, stratified for TSH < or ≥3.0μIU/mL. Thyroid autoimmunity was defined by presence of anti-thyroid peroxidase, -thyroglobulin and/or -thyroid receptor antibodies.

RESULTS

Mean age of studied women was 38.4 ± 5.0 years; their mean AMH was 1.3 ± 2.0 ng/mL and mean TSH 1.8 ± 0.9 μIU/mL. Thyroid autoimmunity was present in 11.1 % of patients. Women with TSH <3.0μIU/mL presented with significantly higher AMH compared to those with TSH ≥3.0μIU/Ml (P = 0.03). This difference remained significant after adjustment for thyroid autoimmunity as well as age (P = 0.02).

CONCLUSIONS

Even after adjustment for thyroid autoimmunity and age, TSH <3.0μIU/mL in euthyroid infertility patients is associated with significantly better FOR (higher AMH) than TSH ≥3.0μIU/mL. This observation suggests a direct beneficial effect of lower TSH levels on follicular recruitment, and warrants investigations of thyroxin supplementation in infertile women with TSH levels ≥3.0μIU/mL in attempts to improve FOR.

Anti-Mullerian hormone as a predictor of ovarian reserve in ART protocols: the hidden role of thyroid autoimmunity

BACKGROUND

Protocols of controlled ovarian hyper-stimulation (COH) require, as a crucial step, the identification of reliable predictors of ovarian reserve. Anti-Mullerian hormone (AMH) is one of the most reliable predictors of ovarian reserve but other factors including autoimmune thyroid diseases (ATD) have been associated with reduced fertility and poor COH outcome. Aim of the present study was to evaluate the relationship between ATD and AMH, and their role on the outcome of COH.

METHODS

The study group included 288 sub-fertile euthyroid women aged less than 40 years attending a single center for Reproductive Medicine. Among them, 55 were ATD-positive and 233 ATD-negative. The serum levels of AMH, FSH, LH, estradiol (E2), and TSH were measured before COH. The ratio between serum E2 concentration on the day of oocytes pick-up and the total dose of administered recombinant FSH (r-FSH) (E2/r-FSH ratio) was calculated.

RESULTS

The serum levels of AMH were significantly related to E2/r-FSH ratio, total dose of r-FSH and number of M II oocytes, both in ATD-positive and ATD-negative women. Within the low stratum of AMH levels, the presence of ATD did not further affect the outcome of COH. When the serum levels of AMH were in the high stratum, the presence of ATD significantly affected the E2/rFSH ratio, the total dose of r-FSH and the number of M II oocytes.

CONCLUSIONS

The probability of a poor response to COH is high, and independent from ATD, in women with low AMH serum levels. In women with a good ovarian reserve, as assessed by high AMH serum levels, the presence of ATD impairs the outcome of COH.