trying to conceive with abnormal thyroid

[thetaetazeta]

Dear Doctor,

My wife is 32 yrs old, no previous medical issues.

4/2006 - TSH 2.4

11/2006 - delivery at 34/40

Pregnancy vitamin taken during pregnancy and lactation included 250mcg iodine / day.

Progressive lethargy over the last 8 months put down to sleep deprivation.

Ceased lactation 10/2007 and currently trying to conceive. Mestral cycles are 30-40 days and she does not appear to be ovulating.

29/02/08 TSH - 6.9  (collection at 2100)

5/3/08  TSH - 3.2 (collection 0800 same lab)   FT4 16 (10-20)  FT3 4.8 (3.5 - 6)
TPO abs >1300 ( <60)    anti Thyroglobulin Abs - 194 (<60)

Examination by local endocrinologist identified no goitre and plan was to recheck bloods in 2 months. Menstral problems explained by post lactation luteal phase defect.

Questions:

1/ What would you suggest is an appropriate starting dose of T4 (wt 65kg)?

2/ Given there seems to be a bit of research suggesting increased iodine can increase hypothyroidism and in australia there is moderate rates of deficiency what would you suggest supplementation wise? I was thinking about ordering a 24hr urine iodine concentration and supplementing according to results?

3/ Would you normally order a screening ultrasound given examination is normal?

4/ Do you normally recommend selenium supplementation continue into pregnancy?

5/ Could you comment on the dramatic change in TSH values only a few days apart. I have read about a late evening TSH surge?? Is it of any significance?

6/ What is the chance of the thyroid problem exacerbating the luteal phase defect?

7/ My wife has a mouth full of mercury amalgam fillings, is there any evidence to recommend precautionary removal?

8/ Does the actual level of antibody relate to disease activity and symptoms in any way in a particular person? eg should it be followed over time to assess risk of miscarriage / prematurity?

9/ Should you screen for any other autoimmune conditions? Any other aspects to management?

Thankyou very much for your time.

[thetaetazeta]

OBJECTIVES: The impact of dental amalgam removal on the levels of anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies was studied in patients with autoimmune thyroiditis (AT) with and without mercury allergy. METHODS: Thirty-nine patients with AT were tested by an optimized lymphocyte proliferation test MELISA® for allergy (hypersensitivity) to inorganic mercury. Patients were divided into two groups: Group I (n = 12) with no hypersensitivity to mercury and Group II (n = 27) with hypersensitivity to mercury. Amalgam fillings were removed from the oral cavities of 15 patients with hypersensitivity to mercury (Group IIA) and left in place in the remaining 12 patients (Group IIB). The laboratory markers of AT, anti-TPO and anti-Tg autoantibodies, were determined in all groups at the beginning of the study and six months later. RESULTS: Compared to levels at the beginning of the study, only patients with mercury hypersensitivity who underwent amalgam replacement (Group IIA) showed a significant decrease in the levels of both anti-Tg (p=0.001) and anti-TPO (p=0.0007) autoantibodies. The levels of autoantibodies in patients with or without mercury hypersensitivity (Group I and Group IIB) who did not replace amalgam did not change. CONCLUSION: Removal of mercury-containing dental amalgam in patients with mercury hypersensitivity may contribute to successful treatment of autoimmune thyroiditis.

http://node.nel.edu/?node_id=1511

[Mark Lupo, M.D.]

This question is very complicated and a little beyond the scope of the forum.  In general, it appears she has Hashimoto's Thyroiditis with mild hypothyroidism and treatment is reasonable, particularly if additional pregnancies planned -would usually start w/ 50-75mcg of T4 in these cases.  Selenium needs more study before it can be universally recommended in women with antibodies during pregnancy - initial studies seem promising.  Not enough data to recommend removal of mercury fillings.  Ultrasound is reasonable given the link between inflammation and increased cancer risk.  No other routine autoimmune screening is recommended at this point.