Abstract
The thyroid gland and gonadal axes interact continuously before and during pregnancy. Hypothyroidism influences ovarian function by decreasing levels of sex-hormone-binding globulin and increasing the secretion of prolactin. In women of reproductive age, hypothyroidism can be reversed by thyroxine therapy to improve fertility and avoid the need for use of assisted reproduction technologies. For infertile women, preparation for medically assisted pregnancy comprises controlled ovarian hyperstimulation that substantially increase circulating estrogen concentrations, which in turn can severely impair thyroid function. In women without thyroid autoimmunity these changes are transient, but in those with thyroid autoimmunity estrogen stimulation might lead to abnormal thyroid function throughout the remaining pregnancy period. Prevalence of thyroid autoimmunity is significantly higher among infertile women than among fertile women, especially among those whose infertility is caused by endometriosis or ovarian dysfunction. Presence of thyroid autoimmunity does not interfere with normal embryo implantation, but the risk of early miscarriage is substantially raised. Subclinical and overt forms of hypothyroidism are associated with increased risk of pregnancy-related morbidity, for which thyroxine therapy can be beneficial. Systematic screening for thyroid disorders in pregnant women remains controversial but might be advantageous in women at high risk, particularly infertile women.
Key Points
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Hypothyroidism is due mainly to chronic autoimmune thyroiditis and is associated with increased morbidity during pregnancy
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Hypothyroidism associated with infertility seems to be increased only in women with ovulatory dysfunction, whereas the frequency of thyroid autoimmunity is raised in infertile women with endometriosis and ovulatory dysfunction
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In spontaneous and medically assisted pregnancies the presence of thyroid autoimmunity is associated with a significantly raised frequency of miscarriages, even when thyroid function is apparently normal
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Screening for thyroid dysfunction, autoimmunity or both should be performed as part of the work-up in women with infertility and other well-defined high-risk conditions
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Levothyroxine therapy should be administered for subclinical and overt hypothyroidism, especially if menses are irregular, assisted reproductive technologies or controlled ovarian hyperstimulation have been used, and during pregnancy
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Acknowledgements
Personal studies included in this Review were made possible thanks to support to K Poppe from the Willy Gepts Foundation. D Glinoer acknowledges the support of the Ministère de la Communauté Française (Administration Générale de l'Enseignement et Recherche Scientifique) within the framework of Actions de Recherche Concertée. We thank all our colleagues from the Center for Reproductive Medicine, Brussels, Belgium, for providing study data. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.
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Poppe, K., Velkeniers, B. & Glinoer, D. The role of thyroid autoimmunity in fertility and pregnancy. Nat Rev Endocrinol 4, 394–405 (2008). https://doi.org/10.1038/ncpendmet0846
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DOI: https://doi.org/10.1038/ncpendmet0846
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