Thyroid f and art

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Information about Thyroid f and art

Published on February 24, 2014

Author: elnashar

Source: slideshare.net

Thyroid function and ART Am Ass of endocrinology, 2013 Up To date, 2012 Aboubakr Elnashar Benha university Hospital, Egypt

Contents I. Thyrotoxicosis II. Hypothyroidism III. SCH IV. AITD V. ART and thyroid function Recommendations

I. Thyrotoxicosis  Hormonal changes.  Estrogen levels: 2- to 3-fold higher {SHBG changes or increase in free estrogen levels}

Fertility Reduced fertility although most thyrotoxic women remain ovulatory (Sturgis et al,1952). Infertility: 5.8% (Joshi et al., 1993)

II. Hypothyroidism Screening: /5 yrs beginning at 35y /2 yrs beginning at 60y, or any symptoms suggesting hypothyroidism (Sperof et al, 2010)

 Hormonal changes. Gn levels: normal. However, blunted or delayed LH response to GnRH PRL ± increased {hypothalamic TRH increasing both TSH and PRL }: ±Galactorrhea These disturbances disappear after T4 administration.

III. Sub Clinical Hypothyroidism (SCH) SCH and infertility TSH: significantly higher compared with the controls.

SCH and miscarriage TSH: high More frequent miscarriages Screening in RM. Am Ass of endocrinology, 2013 Up Todate, 2013

SCH and OD: OD: SCH: 6.3% SCH precocious ovarian failure: 40% OD: 15% (Abalovich et al. 2007). Screening In OD (Lincoln et al.1999; Poppe et al, 2007).

SCH and fertilization failure Both Gn and T4 necessary to achieve maximum fertilization rates and blastocyst development (Cramer et al. 2003) Serum TSH levels are a significant predictor of fertilization failure in women undergoing IVF.

Treatment with LT4: normalize PRL levels normal LH responses to LHRH reduce menstrual disturbances increase the chances of spontaneous fertility

IV. AITD Prevalence: 5 and 15%: most common endocrine disorders in women of reproductive age. often undiagnosed {No overt thyroid dysfunction for several years} (Poppe et al, 2007). Formal names Thyroid Peroxidase Antibody : TPO-Ab Thyroglobulin Antibody: Tg-Ab

AITD and infertility Most studies: increased prevalence of AITD (Kaprara et al, 2007, Krassas et al, 2008). Infertility Control 65% 7% Reference Roussev etal.(1996) 81% 41% Kaider et al (1999) Reimand et al.(2001) 10% 15%

AITD and PCOS: AITD in PCOS: 3-fold greater than controls. (Janssen et al. , 2004) Elevated TPO-Ab1 and TG-Ab2 US thyroid hypoechoic areas3 Elevated serum TSH 1. Thyroid Peroxidase Antibody 2. Thyroglobulin Antibody 3. US hypoechoic areas characteristic of AITD, PCOS 27% 42% 11% Control 8% 6.5% 2%

AITD and Endometriosis: No association (Petta et al, 2007). Increased prevalence of AITD in endometriosis (Poppe et al, 2002).

AITD and RM: TPOAb measurement should be considered when evaluating patients with RM (Grade A) Am Ass of endocrinology, 2013 TSH and thyroid peroxidase antibodies Up To date, 2013

V. ART and Thyroid function COS and thyroid function E2 levels become very high (1470–2203 pmol/liter or 4000–6000 ng/liter): depends on the type and duration of COH. : strain on the hypothalamic-pituitary-thyroid axis: impair TH distribution and kinetics. : increase in serum T4- binding globulin (TBG).

Significant increase in TSH {rapid 10-fold E2 increase after COH (3492 vs. 359 pmol/liter} Before COH TSH mIU/L 1.8 2.3 After COH 3.3 3.2 Reference FT4 ng/L 13.2 12.9 Poppe et al, 2004, 2005 Muller et al., 2000 12.4 14.4 Poppe et al, 2004, 2005 Muller et al., 2000

OHSS and thyroid function marked increase of E2 and TBG: more severe thyroid function changes

COS in hypothyroid-treated women: Rapid increase (already after 4–6 wk gestation) in T4 is required to maintain euthyroidism. When conception had been achieved after ART: The timing of such increased requirement is more rapid and pronounced

Recommendation  Screening for thyroid disorders Universal screening: not recommended for patients who are planning pregnancy, including ART. Am Ass of endocrinology, 2013 1. RM 2. Endometriosis and OD {increased prevalence of AITD which is risk factor for the development of hypothyroidism}. 3. Menstrual irregularities, hyperprolactinemia {LT4 therapy has beneficial effect}. Before COS {severe changes in serum TSH and FT4 may occur} (Poope et al, 2008).

 ART could be postponed First treat hypothyroidism and normal menses restored {avoiding medical and psychological burden of ART} (Poppe et al, 2007).  LT4 administration on ART: No beneficial impact (Negro et al, 2005).

Treatment with L-thyroxine Normal TSH and planning pregnancy, including ART in the immediate future, if they have 1. Positive TPOAb, particularly when there is a history of miscarriage or hypothyroidism. 2. TSH is greater than 2.5 mIU/L Am Ass of endocrinology, 2013, Grade B

LT4 dosage should be increased 1. To obtain TSH < 2.5 mIU/L before COS {latter procedure increases TH demands}. 2. AITD treated with LT4 and developed OHSS {E2 increase sharply and markedly: severe hypothyroidism (TSH, 42 mIU/L) {Association between OHSS and AITD}. :increase daily LT4 dosage 4 wk before starting the COH (Poppe et al, 2008) 2. Spontanous pregnancy: by 30% 3. Pregnancy after COS (with Gn stimulation or oral medications): by 32% (Davis et al., 2007)

Thank you Aboubakr elnashar

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