High Anti-thyroid Antibodies:
Associated with Adverse Pregnancy Outcomes
Even among Euthyroid Women
Dr. John C.
Lowe
Editor-in-Chief
March 8, 2010
Women often contact us to express a common concern. Their
doctors have told them that their high anti-thyroid antibody
levels are of no importance to their health. The women also tell
us how their doctors justify this belief to them: “You’re
‘euthyroid,’ the doctors explain. “That means your TSH is ‘in
range.’ And when your TSH is in range, your thyroid function is
just fine. So don’t worry about the antibodies.”
But two groups of women do remain concerned; some of them are
even fearful. Most of the women in both know that high
anti-thyroid antibodies mean they have autoimmune thyroid
disease. They also have read enough to know that an in-range TSH
level is no assurance whatever that a person has enough thyroid
hormone regulation to be healthy.
One group of the women is concerned about their high
anti-thyroid antibody levels because they aren’t able to get
pregnant. They fear that their autoimmune thyroiditis is
responsible for their infertility.
The second group of women remain concerned about their high
anti-thyroid antibodies because they’ve had troubled or failed
pregnancies. They, too, suspect that autoimmune thyroid disease
is responsible.
I’ll be forthright and say here that both groups of women do
indeed have good reason for concern over their anti-thyroid
antibody levels. Below I support this proposition by briefly
reviewing some of the relevant evidence. That evidence, to give
a more specific proposition, shows this—even in women with
in-range TSH and thyroid hormone levels, high anti-thyroid
antibodies are associated with both infertility and complicated
and failed pregnancies.
Ovarian stimulation and in vitro fertilization. In 2009, Italian
researchers wrote, “Anti-thyroid antibodies, even if not
associated with thyroid dysfunction, are suspected to cause a
poorer outcome of in vitro fertilization.” (Italics mine.) They
analyzed patients’ records for the prevalence of autoimmune
thyroiditis among infertile women who had reference range TSH
and thyroid hormone levels. The prevalence of high antibodies in
euthyroid women was 10.5%.
Some of the women with autoimmune thyroiditis didn’t undergo
thyroid hormone therapy. Compared to control women, these
untreated women didn’t respond as well to ovarian stimulation
and in vitro fertilization.
The researchers noted that women who used T4 responded better to
ovarian stimulation. However, they responded no better to in
vitro fertilization than did women with autoimmune thyroiditis
who didn’t undergo thyroid hormone therapy. But women who were
treated with combined thyroid hormone, aspirin, and prednisolone
responded as well to in vitro fertilization. In fact, they
responded as well as women who didn’t have autoimmune
thyroiditis.
The findings from this Italian study support the 2008 findings
of Spanish researchers.[6] These researchers found that women
with implantation failure had a higher incidence of both thyroid peroxidase (TPO) and anti-thyroglobulin antibodies—despite the
patients’ TSH and free T4 levels being in-range.
The Spanish researchers also found that both types of
anti-thyroid antibodies were higher in women with “unexplained
infertility” than in women with recurrent spontaneous abortion.
(This is an important finding in that women with recurrent
spontaneous abortion also have a high incidence of anti-thyroid
antibodies.[3,4,5]) And once more, the women with unexplained
infertility had in-range TSH and free T4 levels. The Spanish
researchers wrote that thyroid autoimmunity in euthyroid women
is “strongly” related to both unexplained infertility and
implantation failure.[6]
Euthyroid autoimmune thyroiditis. In a review 2009 paper,[1] Dr.
R. Gärtner pointed out that women who are euthyroid but have
high thyroid peroxidase antibodies more often have miscarriages,
preterm deliveries, and postpartum thyroiditis. (He believes
that if these euthyroid women begin taking T4 early in their
pregnancies, they’re less likely to have pregnancy
complications.)
Indeed, whether the women are euthyroid or hypothyroid, if they
have high anti-thyroid antibodies, they are more susceptible to
reproductive problems. In 2000, researchers in Greece found that
compared to control women, women with recurrent spontaneous
miscarriage had a higher incidence of high anti-thyroid
antibodies.[3] In 2004, Israeli researchers found a
statistically significant association between thyroid peroxidase
antibodies recurrent miscarriages[4] And in 2008, Iranian
researchers reported that compared to controls, women with
recurrent spontaneous abortions had a significantly higher
incidence of both thyroid peroxidase and anti-thyroglobulin
antibodies. They concluded, “. . . thyroid autoimmunity was
independently associated with a higher risk of recurrent
abortion.”[5]
Subclinical hypothyroidism. Dr. Gärtner noted[1] that if a
pregnant mother isn’t euthyroid but has subclinical
hypothyroidism, this may impair normal development of the fetus.
The mother, he wrote, should undergo thyroid hormone therapy
even when her TSH is within the upper end of the reference
range. And again, for emphasis perhaps, he wrote, “Special care
is necessary in women with elevated TPO antibodies, because
these [women] more often develop postpartum thyroiditis.”
Conclusion. The research literature contains sufficient evidence
that high anti-thyroid antibodies are associated with
infertility and troubled pregnancies. Because of this, in my
opinion, if you’re a euthyroid woman with high anti-thyroid
antibodies, and you’re concerned that these may be associated
with your infertility or problematic pregnancies, your concern
is warranted.
Let your concern motivate you. If you want to continue working
with your current clinician who has been mistaken about the
issue, then share the research I’ve cited in this article with
him or her. Hopefully he or she will cooperate with you so as to
relieve your concerns. If not, however, let your concern
motivate you to find another clinician who will cooperate with
you. In either case, work with the clinician you choose to
relieve any health problems you have related to your autoimmune
thyroiditis—and especially, of course, any reproductive problems
you have.
References
1. Gärtner, R.: Thyroid disorders during pregnancy.
Dtsch. Med.
Wochenschr., 134(3):83-86, 2009. (Medizinische Klinik Innenstadt
der Universität München.
roland.gaertner@med.uni-muenchen.de2.)
2. Revelli, A., Casano, S., Piane, L.D., et al.: A retrospective
study on IVF outcome in euthyroid patients with anti-thyroid
antibodies: effects of levothyroxine, acetyl-salicylic acid and
prednisolone adjuvant treatments. Reprod. Biol. Endocrinol.,
7:137, 2009. (Reproductive Medicine and IVF Unit, Department of
Obstetrical and Gynecological Sciences, University of Torino,
OIRM-S, Anna Hospital, Torino, Italy.
fertisave@yahoo.com.)
3. Dendrinos, S., Papasteriades, C., Tarassi, K., et al.:
Thyroid autoimmunity in patients with recurrent spontaneous
miscarriages. Gynecol. Endocrinol., 14(4):270-274, 2000. (Second
Department of Obstetrics and Gynecology, University of Athens,
Greece.)
4. Marai, I., Carp, H., Shai, S., et al.: Autoantibody panel
screening in recurrent miscarriages. Am. J. Reprod. Immunol.,
51(3):235-240, 2004. (Department of Medicine 'B', Center for
Autoimmune Diseases, Sackler Faculty of Medicine, Tel-Aviv
University, Tel Hashomer, Israel.)
5. Iravani, A.T., Saeedi, M.M., Pakravesh, J., et al.: Thyroid
autoimmunity and recurrent spontaneous abortion in Iran: a
case-control study. Endocr. Pract., 14(4):458-464, 2008.
(School of Medicine, Medical Sciences/University of Tehran,
Tehran, Iran. Iravani_amir@yahoo.com.)
6. Bellver, J., Soares, S.R., Alvarez, C., et al.: The role of
thrombophilia and thyroid autoimmunity in unexplained
infertility, implantation failure and recurrent spontaneous
abortion. Hum. Reprod., 23(2):278-284, 2008. (Instituto
Valenciano de Infertilidad (IVI), University of Valencia, Plaza
de la Policía Local, 3, 46015 Valencia, Spain.
jbellver@ivi.es.)