It’s not uncommon for women to experience 2-3 miscarriages before they are offered diagnostic testing to determine the cause. Although there are multiple considerations to be made, such as low luteal progesterone, elevated homocysteine and autoimmune disease such as Lupus, elevated thyroid antibodies (TPO) is becoming a well recognized cause of early pregnancy loss(1). Not only does a positive TPO increase risk of miscarriage, it also is a predictor for premature labour and pregnancy complications once women finally do achieve pregnancy (2). Women who are looking to get pregnant are not universally screened for thyroid antibodies, although evidences suggests that upwards of 55% of women with elevated TPO or subclinical low thyroid are missed if we only screen women with traditional risk factors for hypothyroidism such as family history (3).
If we offered a woman the option to be screened following her first miscarriage to prevent a second, she’d jump at the chance to avoid the heartache and to get to the bottom of what’s causing the problem.
TPO is an auto-antibody directed at the thyroid gland. We generally see lower levels of fertility and recurrent miscarriage in women with positive TPO and subclinical or undiagnosed hypothyroidism (4–6) (meaning their thyroid is low, but their lab work is almost normal), and we can help these women achieve pregnancy by addressing thyroid imbalances through diet, supplementation such as selenium (7) and thyroid hormone (8).
The reason TPO seems to be relevant is that it’s not only a marker of disturbed thyroid function, but it signifies autoimmunity and inflammation (9). The immune system is activated and recruited to cause inflammation in the thyroid, and women should be treated not only with desiccated thyroid hormone, but also with a whole body approach that lowers antibodies levels and reduces inflammation.
There is very strong evidence that elevated TPO alone is a risk factor for recurrent miscarriage, even in women who have thyroid hormones in the normal range. The higher the TPO on testing, the greater risk for miscarriage, and thyroid related symptoms such as fatigue (10). Conventionally Medical Doctors only test TSH, which can often be normal in a woman with recurrent TPO-related miscarriage. If we treat her thyroid (despite normal TSH) we can improve her chances of pregnancy (11), reduce gestational diabetes, and prevent pregnancy complications.
We take recurring miscarriage seriously. There is too much evidence for how to support this group of women to use a “wait and see” approach.
Recurrent miscarriage is an emotional and difficult aspect of infertility, and we work hard to ensure that women are assessed as soon as possible for the cause of her loss. Simple lab tests can distinguish between the possible causes of recurrent miscarriage, and can guide our doctors in supporting women to prevent future losses and achieve healthy pregnancies.
- Huchon C, Deffieux X, Beucher G, Capmas P, Carcopino X, Costedoat-Chalumeau N, et al. Pregnancy loss: French clinical practice guidelines. Eur J Obstet Gynecol Reprod Biol. 2016 Jun;201:18–26.
- Bhattacharyya R, Mukherjee K, Das A, Biswas MR, Basunia SR, Mukherjee A. Anti-thyroid peroxidase antibody positivity during early pregnancy is associated with pregnancy complications and maternal morbidity in later life. J Nat Sci Biol Med. 2015 Dec;6(2):402–5.
- Horacek J, Spitalnikova S, Dlabalova B, Malirova E, Vizda J, Svilias I, et al. Universal screening detects two-times more thyroid disorders in early pregnancy than targeted high-risk case finding. Eur J Endocrinol. 2010 Oct;163(4):645–50.
- Vissenberg R, Fliers E, van der Post JAM, van Wely M, Bisschop PH, Goddijn M. Live-birth rate in euthyroid women with recurrent miscarriage and thyroid peroxidase antibodies. Gynecol Endocrinol Off J Int Soc Gynecol Endocrinol. 2016;32(2):132–5.
- Meena M, Chopra S, Jain V, Aggarwal N. The Effect of Anti-Thyroid Peroxidase Antibodies on Pregnancy Outcomes in Euthyroid Women. J Clin Diagn Res JCDR. 2016 Sep;10(9):QC04–7.
- Meena A, Nagar P. Pregnancy Outcome in Euthyroid Women with Anti-Thyroid Peroxidase Antibodies. J Obstet Gynaecol India. 2016 Jun;66(3):160–5.
- Mao J, Pop VJ, Bath SC, Vader HL, Redman CWG, Rayman MP. Effect of low-dose selenium on thyroid autoimmunity and thyroid function in UK pregnant women with mild-to-moderate iodine deficiency. Eur J Nutr. 2016 Feb;55(1):55–61.
- Debiève F, Dulière S, Bernard P, Hubinont C, De Nayer P, Daumerie C. To treat or not to treat euthyroid autoimmune disorder during pregnancy? Gynecol Obstet Invest. 2009;67(3):178–82.
- Ticconi C, Giuliani E, Veglia M, Pietropolli A, Piccione E, Di Simone N. Thyroid autoimmunity and recurrent miscarriage. Am J Reprod Immunol N Y N 1989. 2011 Dec;66(6):452–9.
- Ott J, Promberger R, Kober F, Neuhold N, Tea M, Huber JC, et al. Hashimoto’s thyroiditis affects symptom load and quality of life unrelated to hypothyroidism: a prospective case-control study in women undergoing thyroidectomy for benign goiter. Thyroid Off J Am Thyroid Assoc. 2011 Feb;21(2):161–7.
- Vissenberg R, van Dijk MM, Fliers E, van der Post J a. M, van Wely M, Bloemenkamp KWM, et al. Effect of levothyroxine on live birth rate in euthyroid women with recurrent miscarriage and TPO antibodies (T4-LIFE study). Contemp Clin Trials. 2015 Aug 5;