Thyroid Cancer / Nodules & Hyperthyroidism Expert Forum
Subclinical Hyperthyroidism and Fertility
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Questions in the Thyroid forum are answered by Mark Lupo, MD. Topics covered include Goiter, Graves Disease, Hyperthyroid, Parathyroid/Calcium Problems, Thyroid Cancer, Thyroid Nodules/Cysts, Thyroiditis, Thyroid & Pregnancy, Thyroid Stimulating Hormone (TSH), Thyroid Tests, and Thyroid Surgery.

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Subclinical Hyperthyroidism and Fertility

I have been diagnosed with Subclinical Hyperthyroidism as well as Polycystic Ovary Syndrome (PCOS).  This journey started when I had low TSH levels about 2 years ago and included a couple different endocrinologists and multiple tests (including the most recent, Thyroid Uptake and Scan) along the way. I do have some nodules, but after 2 ultrasounds and a biopsy, they are not concerned with them. They have prescribed Metformin for the PCOS, but I am still not ovulating, so they were going to give me Clomid to continue to help with the infertility.  However, they decided to try and tackle the hyperthyroidism first.  They suggested RAI as "it's the most commonly used in the US", but that wasn't a good enough reason for me.  So, now I'm looking into my options.  My TSH has been between .014 and .081 in the last 2 years, with all other levels normal (I believe).  My most recent blood work (drawn 4/26/13) shows:
TSH: 0.081
T4 Free: 1.04
T3 Total: 1.47
T3 Free: 3.63
Thyroglobulin: 70.4
Thyroglobulin Aby: <0.9
Thyroid Peroxidase Antibody: 15
Thyroid Stim Ig: 88

This month marks 2 years that my husband and I have been trying to get pregnant, so the RAI and ADT don't seem to be great options for the stage of life we're in.  I'd prefer not to have surgery, but it's always an option.  Is it even necessary to treat subclinical hyperthyroidism? I've found conflicting reports especially when it comes to pregnancy. Is it possible to control it with diet and such for now and deal with more permanent options later (after children)?  My resting heart rate is 75-80 typically, so I'm not too concerned with it being serious, but I don't want to place myself (or potential children) at risk by going ahead with the Clomid and other fertility treatments.  Is RAI what you would recommend as the best option, and just wait a year before trying to conceive again?  I'm so conflicted and it's hard to find answers, so any help you can give would be greatly appreciated!
Is the subclinical hyper due to autonomy in the nodule(s)?  The TSI is negative (less likely graves') -- this diagnosis would be based on the I-123 scan w/ comparison to ultrasound.

TSH consistently less than 0.1 (like yours) may cause fertility problems.  Treatment options are ATDs (commonly used, even if planning pregnancy), I-131 (pregnancy plans on hold at least 6 mos), or surgery (extent - partial vs total -depending on cause of hyper).

Would discuss with your endocrinologist as there is not one right answer.
I forgot to include the Uptake and Scan results:

The 6 hour uptake was 34.1% and the 24 hour uptake was 51.3%.

Heterogeneous increased uptake in both thyroid lobes, more pronounced on the right and asymmetric enlargement of the right thyroid lobe corresponding to multinodular goiter on prior thyroid ulstrasound.

The constellation of findings above is compatible with toxic multinodular goiter.
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