Low Tsh Levels And Antithyroid Treatment Before Ivf - Graves' Disease and Thyroid Discussion - Living with Graves Disease

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Low Tsh Levels And Antithyroid Treatment Before Ivf

TSH ivf pregnancy PTU RAI MMI

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#1 hopefuldad

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Posted 09 November 2020 - 07:50 PM

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My wife was diagnosed with GD after completing blood tests in preparation for infertility treatment.  We have been trying to get our levels within range before proceeding with IVF.  Treatment for GD started with PTU, however two weeks in my wife had a severe allergic reaction and had to switch to MMI.  We were discouraged and felt that this would significantly delay our plans to get pregnant.  Here are our lab results after 4 months of treatment and currently taking 25 MG Methimazole

 

6/14/20 7/31/20 9/1/20 9/23/20 10/23/20

TSH <0.1 <0.1 <0.1 <0.1 <0.1

Standard Range

0.4 - 4.2 uIU/mL 

 

T4 3.7 4.2 2.0 1.5 1.1

Standard Range

0.8 - 1.7 ng/dL

 

T3 546 316 221 158

Standard Range

50 - 170 ng/dL

 

Our doctor’s plan for now is to get our TSH in range, then slowly decrease our MMI dose and reintroduce low dose PTU.  If my wife does not have a good reaction to PTU, our doctor may push us to RAI, which we want to avoid if we can.

 

My questions:

 

Since T4 and T3 levels are currently in range, is it necessary to get TSH levels up?

 

Is there anything else we can do to get the hyperthyroidism into remission.  Our goal is to avoid RAI and get pregnant with minimal dosage of antithyroid medication.

 

Are there any other tests we should be asking for? (antibody tests, tests to confirm it is actually Graves?)

 

I have done some research about the importance of TSH levels, and worried that continuous treatment with antithyroid medication is not the best route, given where T3 and T4 levels are.

 

Any advice or help is much appreciated. Thank you!

 




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#2 Allies

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Posted 09 November 2020 - 11:50 PM

Hi hopefuldad

Kudos to you for supporting your wife :D
 

Since T4 and T3 levels are currently in range, is it necessary to get TSH levels up?

The short answer to that is "no" :)

Both the American and European guidelines advise practitioners to titrate antithyroid medication according to thyroid hormone levels - FT3 (or total T3) and FT4. One of the authors of the most recent Europen guidelines, George Kahaly, recently rather spelled it out by saying that titrating medication in response to FT3 and FT4 can help to prevent "long-term suppression of serum TSH" with no side effects "from month 3 through the end of MMI treatment." (p.13)

[From:
'Prospective Trial of Functional Thyrotropin Receptor Antibodies in Graves Disease'
J Clin Endocrinol Metab. 2020 Apr; 105(4): e1006e1014.
George J Kahaly, Tanja Diana, Michael Kanitz, Lara Frommer,and Paul D Olivo

https://www.ncbi.nlm...les/PMC7067543/ ]

Speaking as a grave's patient who's original doctors disregarded this advice, I would say there certainly seems to be a ring of truth to it. My TSH, even after five years (the last two of those off any medication) is usually at the very least under range and only goes into range if my thyroid hormones become too low. It annoys me no end to think this low TSH could have been avoided if the endos had only followed the guidelines properly in the first place!
 

Are there any other tests we should be asking for? (antibody tests, tests to confirm it is actually Graves?)

I believe it's a good idea to be tested for Grave's antibodies as these are more definitive than scans or guesswork. There's also the concern that these antibodies can cross the placenta quite readily and effect the growing fetus; so not monitoring these antibodies prior to and during pregnancy would be rather remiss. You might want to look into this, as I can't remember if this was anecdotal or something I read in a medical paper.

I'm afraid that there's not really a quick fix for autoimmune thyroid problems (other than sheer luck :) ) and it may take a little while to sort it out (sorry). The definitive treatments (RAI or thyroidectomy) don't really offer shorter solutions either, and the hypothyroidism that results from these can effect fertility; plus it can take quite a while to dial in the correct dose and type of thyroid hormone replacement even assuming one has a doctor who is good at this. Antibody-wise RAI is reported to increase these for a time, medical papers usually put this as a few months to a year; people in the trenches with Grave's disease post-RAI report antibodies many years later.

Total thyroidectomy has a much better track record for reducing Grave's antibodies, but even this is not 100% certain and without a thyroid gland one is still left with a period of time needed to get thyroid hormone replacement just right.

Antithyroid medication falls somewhere between the two definitive options and most likely does the job of reducing antibodies better if it's used correctly :)
 

Is there anything else we can do to get the hyperthyroidism into remission.  Our goal is to avoid RAI and get pregnant with minimal dosage of antithyroid medication.

Properly titrated antithyroid drugs go a long way to achieving this (as you are already thinking :) ) If we can figure out what things cause the autoimmune response in the first place and remove or reduce exposure to those things it should help. I discovered that removing dairy fixed long-standing hayfever, but I also learned the hard way that any time we remove things from our diet we need to be mindful that we may also be removing valuable nutrients and will need to get these from other sources.

Many people (but not everyone) report feeling better by going gluten free, some people can't tolerate eggs, or shellfish, or peanuts. We are all rather individual and triggers can be different for different people. Triggers are not always foodstuffs either, other things that might upset a susceptible individual are:
stress, poor sleep, cosmetics, household cleaning agents, mold, chemical fragrances and environmental toxins - there are probably more, but those are the ones that spring to mind

Hope that was helpful and not too long-winded
Allies
:D



#3 mmztcass

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Posted 10 November 2020 - 12:13 PM

Hello hopefuldad:

 

The TSH can take a long time to normalize and it isn't something I would worry about.  

 

What I would want to do if I was wanting to get pregnant, I would want to make sure to get my Free T3 at mid range (ask doctor to order a Free T3 test rather than a T3) and to have the Free T4 at the upper third range.

 

I would then want to have the Graves' thyroid antibodies tests of the TSI (especially) and TRAb done.  The TSI needs to be as low as possible to try for a pregnancy as not to cross the placenta.

 

It looks like that the amount of MMI at 25 mg needs to be reduced to allow for the Free T4 to come up to the upper third range.  

 

May I ask what kind of allergic reaction your wife had to taking the PTU?

 

Here are links from Elaine Moore talking about the Graves' Disease and Pregnancy:

 

https://www.elaine-m...21/Default.aspx

 

https://www.elaine-m...65/Default.aspx



#4 hopefuldad

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Posted 10 November 2020 - 06:48 PM

Hi mmztcass:

 

My wife's reaction to PTU included nausea, high fever, chills, weakness, etc.  The reaction was very severe as her fever went up to 105.   We tried a lower dose, but symptoms would arise approximately 1-2 hrs after.  It is unfortunate, as our understanding is PTU is the only antithyroid medication we can take during the first trimester.  

 

We will request Free T3, TSI, and TRAb test from our doctor and post results.  It sounds like we have to ask our doctor we want to decrease MMI dosage sooner rather than later.  Typically there is a 4 week window between tests to monitor if the dosage is right.  

 

Thanks again for your help and reply!  



#5 Allies

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Posted 11 November 2020 - 03:44 AM

 
My wife's reaction to PTU included nausea, high fever, chills, weakness, etc.  The reaction was very severe as her fever went up to 105.   We tried a lower dose, but symptoms would arise approximately 1-2 hrs after.  It is unfortunate, as our understanding is PTU is the only antithyroid medication we can take during the first trimester.  
 

Just a thought, is there only one manufacturer or supplier of PTU in the States? I'm just wondering if the reaction might have been to the fillers rather than the active ingredient





Also tagged with one or more of these keywords: TSH, ivf, pregnancy, PTU, RAI, MMI


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