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Thyroid dysfunction an d infertility treatment

Journal: Acta Endocrinologica
Manuscript ID 1646-AEB-07-2016
Manuscript Type: Original Article
Keywords: Infertility, Intracytoplasmic sperm injection, Assi sted reproductive
technique, Thyroid profile, Hyperthyroidism

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For Review OnlyTitle Page
Thyroid dysfunction and infertility treatment
Author Details
1. Salima Lalani
Technologist
Aga Khan University, Karachi
[anonimizat]

2. Iman Nizami
Medical Student: [anonimizat], Karachi
[anonimizat]

3. Ahmed Ali Hashmi
Medical Student: [anonimizat], Karachi
[anonimizat]

4. Adnan Saifuddin
Medical Student: [anonimizat], Karachi
[anonimizat]

5. Dr. Rehana Rehman
Assistant Professor
Department of Biological & Biomedical Sciences
Aga Khan University, Karachi
[anonimizat]

Address of Correspondence

Dr. Rehana Rehman
Assistant Professor
Department of Biological & Biomedical Sciences
Aga Khan University, Karachi
[anonimizat]
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Thyroid dysfunction and infertility treatment 1
Abstract 2
Objective: To find out the relationship of thyroid hormone pro file of females with 3
outcomes after intra cytoplasmic sperm injection (I CSI). 4
Method: It was a cross sectional study conducted in Islama bad Clinic Serving Infertile 5
Couple from June 2013 till August 2015. T3 (triiodo thyronine), T4 (thyroxine) and TSH 6
(thyroid stimulating hormone) of 172 consented fema les was estimated before they 7
underwent treatment protocol for ICSI. Pregnant gr oup had ß hCG result more than 25 8
IU/mL while rest were included in nonGpregnant grou p. Both groups were compared by 9
using independent sample tGtest. Pearson correlatio n coefficient was used to associate T3 10
and T4 with other pregnancy variables with their si gnificance. 11
Results: Non pregnant women had significantly higher mean v alues for T3 and T4 as 12
compared to pregnant women (p <0.05, p<0.01). Diffe rence in mean TSH value between 13
nonGpregnant and pregnant women was not significant p=0.08. It was found that T4 gave 14
significant negative association with grading of em bryoGI, blastocysts formed, thickness 15
of endometrium and number of gestational sacs. 16
Conclusion : Disturbance in thyroid profile with raised T4 le vels lead to alteration in 17
endometrial thickness and quality of embryos requir ed for implantation and hence 18
conception. 19
Word count: 195 words. 20 Page 2 of 18
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Key Words: Infertility, intracytoplasmic sperm injection (ICSI ), assisted reproductive 22
techniques (ART), thyroid profile, hyperthyroidism 23
Introduction 24
Infertility is the growing issue around the globe. Estimated 15% population suffers from 25
it.[1] Reasons of infertility may range from poor r eproductive health of either partner or 26
deficiencies of crucial biochemical substances, whi ch are usually overlooked or remain 27
undiagnosed.[1] Hypothyroidism falls in the latter category, where disturbance in thyroid 28
hormones interfere with fertility. Since hypothyroi dism usually remains asymptomatic, 29
therefore it cannot be easily caught as a contribut ing factor of infertility. 30
Hypothyroidism is divided into subGclinical (SCH), clinical and autoimmune conditions, 31
each having a different influence on conception and pregnancies. SCH is a condition 32
known to have mild increase in thyroid stimulating hormone (TSH) serum concentration 33
(≥4.25 mIU/L), while T3 and T4 are within normal ra nge. Clinical hypothyroidism, on 34
the other hand has increased TSH and decreased T4 s erum concentrations. [2] 35
Autoimmune thyroid disease causes antibodies produc tion against thyroid gland and its 36
products – Hashimoto’s disease. In either case, it is the area of concern and major health 37
burden globally. 38
Hypothyroidism has significant interference, in gen eral, for couples who try to conceive 39
and in particular for those who are undergoing infe rtility treatments. Developed countries 40 Page 3 of 18
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have reported hypothyroidism to be 2G4% in fertile group. [3] SCH been recognized as 41
major culprit. It is known that hypothyroidism caus es increase in thyrotropin releasing 42
hormone, which in turn, alters the level of prolact in and luteinizing hormone (LH) 43
response – both are major contributor towards ferti lity. Therefore, any correction of 44
hypothyroidism at initial level can be fruitful for the successful treatment of infertility. 45
[4] 46
On the contrary, state of hyperthyroidism in female s also poses hindrance in the way of 47
conception due to poor reproductive state. Unlike h ypothyroidism, it is a state in which 48
TSH levels are suppressed with T3 and T4 elevated. It may be caused by Plummer’s 49
disease, a state in which selfGregulating nodules a re formed on thyroid gland, which 50
causes the condition of hyperthyroidism. Thyroiditi s, an inflamed thyroid gland is yet 51
another condition which results in hyperthyroidism. Another documented reason for 52
hyperthyroidism is an autoimmune condition, Grave’s disease, in which body produces 53
antibodies that stimulate thyroid gland, resulting in over production of thyroid hormone. 54
[5] 55
Intra cytoplasmic sperm injection (ICSI) is one of such treatment in which proper 56
thyroxin levels are essential for the success of tr eatment. It is known from the literature 57
that TSH is expressed by ovaries, while T3 along wi th thyroid hormone receptors are 58
known to protect apoptosis of granulose cells. Any fluctuation in TSH levels can 59
influence the ICSI in negative way. [6] A decrease in thyroxin may cause early 60
miscarriage which explains its role in implantation . On the other hand, literature suggests 61 Page 4 of 18
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that over production of thyroid hormone does not im pact the assisted reproduction 62
significantly. However, fertile women with hyperthy roidism, autoimmune thyroid 63
disorder in particular, are more prone to miscarria ges, fetal abnormalities etc. [5] 64
A number of studies have been conducted to detect o vulatory dysfunction or infertility 65
with thyroid disorders. [7] Although untreated thyr oid disease can be a cause for 66
infertility as well as subGfertility, limited liter ature is available to explore impact of 67
thyroid dysfunction on infertility treatment proced ures. To add further, a low success rate 68
of ICSI (25G30%) requires the need to identify and elucidate all the treatable factors that 69
could improve implantation after ICSI. [8] Since thyroid dysfunctions can be treated 70
before starting the ICSI, therefore, an early detec tion and treatment of irregularities can 71
contribute to successful ART. Our study was designe d to relate thyroid hormone profile 72
of females with outcome after ICSI to know the impa ct of thyroid profile on success after 73
ICSI. 74
Subjects & Methods 75
The cross sectional study was carried out in “Islam abad Clinic for Serving Infertile 76
Couples” from June 2013 till August 2015, after app roval from the Ethical Review Board 77
on the basis of convenience sampling. Participation was voluntary and ethical clearance 78
was obtained from the Institutional review board. R espondents were given detailed 79
information about the study and were assured of the confidentiality of the data. Informed 80
consent was obtained before the start of the study. 81 Page 5 of 18
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The included females had age range from 20 till 35 years, with normal ovulatory cycles 82
and uterine morphology. Females with known thyroid or other endocrine disorder, 83
endometriosis and polycystic ovarian syndrome (PCOS ) were excluded. Serum T3, T4 84
and TSH were analyzed by Enzyme Linked Immunosorben t Assay (ELISA) after the 85
females were down regulated and had routine blood t ests before initiation of stimulation 86
and treatment procedure. Thyroid tests (T3, T4 and TSH) were measured by Diametra 87
ELISA Kit with sensitivity reported as the lowest d etectable concentration of T3, T4 and 88
TSH that can be distinguished from the Calibrator 0 is 5 ng/dL, 0.4 µg/dL and 0.01 89
mIU/L at the 95 % confidence limit respectively. 90
Females were down regulated with daily injection of Deca Peptyl (gonadotripin releasing 91
hormone agonist) from Day 21 of previous cycle. Fol licle stimulation was done by 92
gonadotrophin injections (Puregon) for fourteen day s; dose was titrated with respect to 93
basal follicle stimulating hormone (FSH) and respon se to stimulation. Follicular 94
monitoring by transvaginal ultrasound (TVS) was don e three to four days after the 95
commencement of the ovarian stimulation till maturi ty of maximum follicles to 20 mm. 96
Human chorionic gonadotropin (β hCG) injection (10, 000 IU) was given and procedure 97
was done 3–6 hours after oocyte recovery on all mor phologically intact eggs in 98
Metaphase II stage as mentioned in our previous stu dy.[8] Fertilization was assessed by 99
development of two pronuclei. Cleavage rate was ass essed by counting the number of 100
cells in the embryo on day three after 24 hours. Em bryos that had six to eight cells on day 101
three were considered to have cleaved at a normal r ate, embryos with five cells or fewer 102
were considered to be slow cleavage, and embryos wi th nine or more cells were 103 Page 6 of 18
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considered to have accelerated cleavage. Embryos we re evaluated on alternate days. All 104
embryos were graded (Grades 1G5) as described by Ak tan et al. [9] 105
Primary Outcome measure 106
Single serum β hCG was obtained in the respondents 14 days after egg collection by 107
aseptic peripheral venipuncture method. TVS was per formed at 8 weeks gestation on the 108
basis of β hCG and TVS results were categorized int o pregnant group comprised of 109
females with β HCG more than 25 IU/mL and cardiac a ctivity on TVS while rest 110
comprised of nonGpregnant group. 111
Statistical Analysis: 112
The data feeding and analysis was done via SPSS (St atistical Packages of Social 113
Sciences) version 15.0. Clinical characteristics we re summarized in terms of frequencies 114
and percentages for qualitative variables (age grou p), mean ± S.D ± SEM for 115
continuous/quantitative variables. Using independen t sample tGtest for quantitative 116
variables performed statistical comparison. Pearson coGrelation was used to relate thyroid 117
status with predictors of pregnancy. In all statist ical analysis, only pGvalue <0.05 was 118
considered significant. 119
Results 120
In the study, 72/172 females conceived with a pregn ancy rate of 42%. Table 1 represents 121
descriptive characteristics of study participants. The comparison of T3, T4 and TSH 122
between pregnant and nonGpregnant women using indep endent sample tGtest, showed 123 Page 7 of 18
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significantly higher mean for T3 and T4 in nonGpreg nant women as compared to pregnant 124
women p <0.049 and <0.01respectively (Table 2). TSH did not give any significant 125
differences in mean value between nonGpregnant and pregnant women, p=0.08. 126
Table 3 reports the Pearson correlation coefficient of T4 with other pregnancy parameters 127
with their significance. It was found that T4 gave significant positive association with 128
poor grading embryos (II, III). T4 gave significan t negative association with grading of 129
embryos I, blastocysts formed, thickness of endomet rium, number of gestational sacs and 130
ratio value of number of sacs to number of blastocy sts. There was no significant 131
association found of T4 with number of oocytes, met aphase II, fertilized, cleaved 132
embryos, grading of blastocysts II and number of tr ansferred embryos. 133
Discussion 134
Adequate levels of circulating thyroid hormones are of primary importance for normal 135
reproductive function. A close relationship between the hypothalamic pituitary ovarian 136
(HPO) and hypothalamic pituitary thyroid (HPT) axis can be explained by the presence 137
of thyroid hormone receptors at the ovarian levels. The role of thyroid hormones on 138
reproductive functions can be explained further by synergy with FSH on LH/hCG 139
receptor to exert direct stimulatory effects on gra nulosa cell function e.g. for production 140
of progesterone required for endometrial receptivit y and blastocyst implantation. [10] 141
Evaluation of thyroid status in the infertile coupl e is not only important because it is 142
significant and most common but also its treatment is very simple and often has 143
preventable effect on infertility. [11] In the pres ent study serum T3 and T4 levels were 144 Page 8 of 18
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found to be significantly increased in infertile no n pregnant females as compared to 145
pregnant females. 146
According to the American Thyroid Association, the thyroid profile of a woman is 147
different at different stages of pregnancy. The gen eral trend is that TSH, T4 and T3 levels 148
are lower as the pregnancy progresses. For example, T4 levels range 5.4 to 11.7 µg/dL in 149
normal, nonGpregnant females while in the third tri mester it ranges from 6.3 to 9.7 µg/dL. 150
[12] Total T3 levels are less consistent: in normal, non Gpregnant women who ranged from 151
60 to 181 ng/dL and range is decreased to 71 to 175 ng/dL in pregnant women. However, 152
by the third trimester the normal range increases a gain to 104 to 182 ng/dL. [12] TSH in 153
normal, nonGregnant females ranges from 0.34 to 4.2 5 mIU/L and it decreases to 0.30 to 154
4.04 mIU/L. [12] 155
In our study, the T3 and T4 levels were significant ly higher in the nonGconception group 156
as compared to those with successful ICSI conceptio ns. In the nonGpregnant, the average 157
T3 levels was 304.2 ng/dL, while in the pregnant wo men is was 278.4 ng/dL. Both of 158
these levels are higher than normal according to th e American Thyroid Association, but 159
they were significantly higher than in the nonGpreg nant women. Similarly, the average T4 160
level was 17.4 µg/dL in the nonGpregnant women whil e it was 15.1 µg/dL in pregnant 161
women. Once again, it is demonstrated that T4 level s are higher than normal, and the T4 162
level in nonGpregnant is significantly higher than that in pregnant women. The TSH 163
levels, however, remained within normal limits but towards lower side despite increasing 164
with pregnancy: 2.1 mIU/L in nonGpregnant females a nd 2.7 mIU/L in pregnant females. 165 Page 9 of 18
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Disturbances in thyroid functions can lead to unsuc cessful pregnancy. [11] Thus high T3, 166
T4 and relatively lower TSH levels in nonGpregnant females in our study explains 167
disruption of HPT axis, and that may be the cause o f treatment failures. 168
TSH levels reflect the integrity of hypothalamic pi tuitary thyroid (HPT) axis and are a 169
“sensitive marker for thyroid gland dysfunction”. D uring ART, increase TSH is attribute 170
to stimulation by HCG and high E2 levels which stim ulate Thyroid binding globulin to 171
cause a decrease in free thyroid hormone and hence raised TSH. [13] In our study, the 172
levels were measured before ovarian stimulation whi ch reflected a low TSH with high T3 173
and T4 in nonGpregnant females, a clear indicative of hyperthyroidism. 174
The number of mature oocytes, fertilized oocytes an d cleaved embryos are all stages of 175
normal embryogenesis. Blastocysts and their morphol ogy are an important factor in the 176
success of embryo transfer because this stage is we ll adapted to implant in the 177
endometrium. There is a grading system in place tha t takes into account expansion of 178
blastocoels, morphology of inner cell mass (ICM), c ohesiveness of trophoectoderm (TE) 179
and presence of excluded blastomeres or fragments f rom the formation of blastocysts, all 180
of which a determinants of successful implantation. [14] The negative correlation implies 181
that higher T4 levels resulted in deterioration o f embryo (blastocyst) quality. The low 182
pregnancy with high T4 can be explained on the basi s of poor quality of blastocyst which 183
is associated with lesser chance of a successful im plantation and conception. [9] Keeping 184
in mind the impact of thyroid dysfunction on blasto cyst implantation and fetoGmaternal 185
morbidities [7] increased awareness about detection of thyroid hormones in the infertility 186 Page 10 of 18
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clinics should be reinforced. 187
There is also a negative association of T4 levels w ith the thickness of endometrium and 188
number of gestational sacs, both conditions that ar e essential for implantation of embryo. 189
Endometrial thickness reflects the maturation of en dometrium prepared to welcome the 190
impending blastocyst. [8] In our study decreased en dometrial thickness due to higher T4 191
levels may be held responsible for development of e ndocrine milieu, which synchronizes 192
with development and attachment of blastocysts. Thi s again suggests that the high T4 193
levels are indicative of an inability to successful ly conceive. 194
Our study has proved the importance of optimal T3 a nd T4 levels on the normal HPO 195
axis with reference to oocyte and embryo parameters . In our study, thyroid profile was 196
performed after down regulation of ovaries and indi cates lack of complete correction of 197
high T4 and T3 in terms of reduced TSH by HPT axis. This is manifested by presence of 198
normal TSH with high T3 and T4 levels. It is a unGc entric study which has small sample 199
size and we did not have their base line thyroid pr ofiles. However, it is the first study that 200
documents that alteration in thyroid profile has an impact on results after ICSI; correction 201
of which may help in improvement of results after i nfertility treatment procedures. 202
Conclusion 203
Hyperthyroidism as indicated by altered thyroid sta tus in our patients was associated with 204
failure of implantation and successful conception a fter ICSI. It is, therefore, 205
recommended that thyroid hormone profile of all inf ertile females should be carried out 206
and corrected before advance infertility treatment procedures. 207 Page 11 of 18
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Disclosure Statement 208
No competing financial interests exist. 209
Funding 210
The project was funded by The Aga Khan University – Research Module Funds of 211
Department of Biological and Biomedical Sciences. 212
213
Word count: 2,240 words. 214
215 Page 12 of 18
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12. Normal reference ranges and laboratory values in pr egnancy [Internet]. 247
Perinatology.com. 2016 (Accessed 27 June 2016 at si te 248
http://perinatology.com/Reference/Reference Ranges/ Reference for Serum.htm ) 249
13. Reinblatt S, Herrero B, Correa JA, et al. Thyroid s timulating hormone levels rise 250
after assisted reproductive technology. J Assist Re prod Genet. 2013; 30(10):1347G 251
1352. doi:10.1007/s10815G013G0081G3. 252
14. Borut Kovačič and Veljko Vlaisavljević. Importance of blastocyst morphology in 253
selection for transfer. In: Dr. Bin Wu, ed. Advance s in embryo transfer. InTech. 254
Mar 2012:161G176. ISBN: 978G953G51G0318G9, at site 255
http://www.intechopen.com/books/advancesGinGembryoG transfer/importanceGofG 256
blastocystGmorphologyGinG selectionGforGtransfer 257
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Table 1 1
Descriptive statistics of study Population 2
Mean Std. Deviation Minimum Maximum
Female age
(years) 32.17 4.82 23.00 41.00
Duration of
infertility (years) 6.54 3.51 2.00 18.00
BMI 23.96 3.55 17.00 30.00
No of
oocytes/patient 7.75 1.63 5.00 12.00
No of oocytes
Metaphase II 7.39 1.66 2.00 11.00
No of oocytes
fertilized 6.14 1.28 2.00 9.00
No of cleaved
embryos 6.05 1.25 2.00 9.00
Grading of
embryos I 2.19 1.54 00 6.00
Grading of
embryos II 2.57 1.12 1.00 5.00 Page 15 of 18
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3
T3 (triiodo thyronine), T4 (thyroxine) and TSH (thy roid stimulating hormone) 4
5 Grading of
embryos III 1.29 0.50 00 2.00
Blastocyst
formed 2.08 0.47 1.00 3.00
Grading of
blastocyst I 1.55 0.81 00 4.00
Grading of
blastocyst II 0.42 0.50 00 1.00
Grading of
blastocyst II 0.15 0.45 00 2.00
thickness of
endometrium 8.80 3.37 3.00 14.00
No of transferred
embryos 1.69 0.60 1.00 3.00
Number of
gestational sacs 0.63 0.80 00 2.00
T3 ng/dL 293.18 61.00 147.54 559.34
T4 µg/dL 16.45 1.39 13.22 19.56
TSH mIU/L 2.41 1.60 1.18 14.86 Page 16 of 18
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Table 2 6
Comparison of Mean Values for T3, T4 and TSH betwee n Pregnant and Non Pregnant 7
Women 8
9
10
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Groups N Mean Standard
Deviation p-value
T3 NonGpregnant 96 304.2 62.41
0.049*
Pregnant 72 278.4 56.59
T4 NonGpregnant 96 17.4 0.82
<0.01
Pregnant 72 15.1 0.83
TSH NonGpregnant 96 2.1 0.76
0.08
Pregnant 72 2.7 2.24
*p<0.05 considered significant using independent sa mple tGtest Page 17 of 18
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Table 3 17
Correlation of T4 with Pregnancy Parameters 18
Correlation of T4 with Pregnancy Parameters r p-value
No of oocytes/patient G0.179 0.102
No of oocytes Metaphase II G0.156 0.156
No of oocytes fertilized G0.179 0.103
No of cleaved embryos G0.125 0.259
Grading of embryos I G0.652 <0.01*
Grading of embryos II 0.54 <0.01*
Grading of embryos III 0.479 <0.01*
Blastocyts formed G0.248 0.023*
Grading of blastocyts I G0.603 <0.01*
Grading of blastocyts II 0.571 <0.01*
Grading of blastocyts III 0.188 0.086
thickness of endometrium G0.57 <0.01*
No of transferred embryos G0.045 0.685
Number of gestational sacs G0.726 <0.01*
Number of sacs/ number of blastocysts * 100 G0.779 <0.01*
*P<0.05 considered significant for Correlation
19 Page 18 of 18
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