18: Thyroid Health & Fertility: Unlocking Optimal Outcomes with McCall McPherson

Welcome to Modern Thyroid and Wellness, the podcast that explores the intricate dance between health, wellness and thyroid, unraveling the threads that weave our vitality together. I'm your host, McCall McPherson, and I'm so thrilled to guide you on this journey to optimal wellness. Today we are digging into one of my most requested topics which is fertility, pregnancy, postpartum, all of these things. And you all have told me you don't feel like there's enough valuable information out, so let's dig in. I will outline a little bit about how this is going to go so you have an expectation of what to expect. So first I want to really just dig into some studies that support our approach at Modern Thyroid Clinic and then I will provide those studies with you in the show notes so you can find them there. We'll also dig in after that to Modern Thyroid Clinics, approach to fertility, pregnancy, et cetera, so you guys can access that too. I'll take you through our approach during pregnancy postpartum. I also want to touch on LDN and then you all have questions from me from Social. If you don't follow me on Social, especially Instagram, this is where I source all of your questions and answer them for these episodes. So please, please tune in and follow me there at McCall McPherson, Pennsylvania. Let's dig in. So let's talk first about thyroid hormones and their role in getting pregnant, ovarian reserve, et cetera. And I just want to read you some stats. What's really interesting is what I've been saying for years, which is thyroid needs to be perfect when we are pre pregnancy planning. So again, like regular medicine now is essentially saying that a TSH Less than 10 doesn't even really need to be treated. It's subclinical, doesn't need to be addressed, wait until it's over 10. But studies over and over and over again show that a more narrow margin for thyroid hormones yields better results. Let's talk about some information. Evidence suggests that deregulated thyroid hormone signaling, particularly reduced T3.3 availability, correlates with diminished ovarian reserve. Also a more tightly regulated TSH, one study shows less than 3, another less than 1.7, is associated with a higher AMH level, a marker for better ovarian reserve. Not surprising. T3 exposure has been shown to enhance follicular growth and survival by granulosa cells and red reducing the apoptosis or the death of those cells, which is again amazing. Subclinical or overt hypothyroidism reduces the number of growing folic follicles and increases follicular atresia leading to premature ovarian aging. Right. And then in zebrafish, T3 supplementation, reversed defects in ovarian function and impaired ovulation. So, so important not only TSH but obviously T3. And then I want to touch also on thyroid autoimmunity and infertility. Women with thyroid antibodies specifically in the study TPO showed higher rates of diminished ovarian reserve and increased level. Increased levels of these antibodies are associated also with a lower AMH antibodies also play a role. Optimizing these leading up to pregnancy during the pre pregnancy planning period is extremely valuable. And again this is something we work on at Modern Thyroid clinic. Let's dig into another study that looks at thyroid function and IVF outcomes for different indications. And I think not only does this apply to ivf, this applies to fertility in general. So let me read you some of the findings I found in this study. Women with high normal tsh, which the definition of high normal to this study is 2.5 to 4.5, still very much within the quote normal limits of standard medicine. These people had a 15% lower live birth rate when compared to women who had a TSH level in the low normal range which was 0.3 to 2.5. Y' all huge. Okay. Subclinical hypothyroidism and fertility meaning an elevated TSH with a normal T4 affected women 2 to 4% in their reproductive age and it was linked to poor fertility outcomes, particularly in women undergoing ivf. Now let's talk about embryo quality. Let's talk about top quality embryos compared to people in the upper range of TSH versus the lower range of TSH. So the people in the upper quartile meaning 2.5 to 4.5 level of TSH would get top quality embryos 58% of the time while compared to people in the lower more narrow margins of TSH would get top quality embryos 66 to 68% of the time. That is extremely statistically significant. The study also found in terms of fertilization and embryo development, higher TSH levels may impair embryo development and fertilization due to subtle thyroid dysfunction. What do we advocate for at Modern Thyroid clinic? Perfect thyroid function. This was especially pronounced in the presence of thyroid antibodies, specifically tpl. Lastly, odd ratios for live birth rate. So how likely women are to have a live birth to completion. The adjusted odd ratios showed that women with TSH levels less than 1.9 had more than twice the likelihood of achieving live births. Comp women with TSH levels of 2.6 to 4.5, y'. All. Can this be any more spot on with our approach at Modern Thyroid clinic? And absolutely what we advocate for. So let's talk about thyroid autoimmunity a little bit more. Different study, but this is Hashimoto or the presence of TPO antibodies, thyroglobulin antibodies. Specifically we're talking about Hashimoto, not Graves. So thyroid autoimmunity is present in 5 to 14% of women. Among infertile women, the presence of Hashimoto's is significantly higher, especially those with unexplained infertility or PCOS where the rate can actually reach almost 27%. Women with Hashimoto's had a 2.26 times higher risk of diminished ovarian reserve. And a study that looks at, you know, these numbers via meta analysis, which is a very powerful form of scientific studies and let's look at pregnancy complications. Another meta analysis, same one actually revealed that women with positive TPO antibodies are 3.9 times higher for risk of having a miscarriage than those without thyroid autoimmunity. And the odds of having a preterm birth in this population are double in women with Hashimoto's compared to women who do not have Hashimoto's. About 20% of quote EU thyroid women with Hashimoto's developed subclinical hypothyroidism during pregnancy, which obviously is then associated with adverse outcomes and premature delivery. So I think you know, a lot of the numbers, numbers in this study for Hashimoto's in particular are basically a manifestation of hypothyroidism. That is either people are actually going into pregnancy already having or they're developing during pregnancy and it's not being appropriately treated. So, so, so important. So those are like some basic studies I pulled. I'll include them again in the show notes. But I want to talk to you now about modern thyroid clinics approach to pre pregnancy planning, pregnancy postpartum. So we consider ourselves pretty neurotic in terms of thyroid care in general. This is very much amplified in our pregnant patients or patients that want to get pregnant. So again, a lot of this is unique, it is tailored per patient. But I still wanted to give you some highlights. So ideally I love to start working with people on pre pregnancy planning anywhere from six to 12 months before they want to get pregnant. If they, you know, have been on birth control for five, 10 years. I like, I really, really like to have ample time to re, kind of create systems and flows in their Hormones that will contribute to successful outcomes. So during pre pregnancy planning, we want to obviously reduce antibodies as much as possible. Whether that's with lifestyle, diet, supplements, stool testing, ldn, we want to reduce those antibodies as much as possible. We want to perfect your thyroid hormones before you're actively pregnancy planing. Because during pregnancy, y' all research and our clinical experience shows there are significant swift shifts and changes in your thyroid hormones and that impacts pregnancy, it impacts success of pregnancy, risk for miscarriage and also the baby baby. So we want to go into it really with a solid foundation knowing and expecting these shifts and changes over time. When women are actively pre pregnancy planning or beginning that process, I always like to either have a foundational form of T4 hormone, which is your inactive thyroid hormone, or discuss the the nature and likelihood that hey, at some point we probably will be adding this I because for several reasons and we'll talk about that in the kind of pregnancy section of this chat. But I like to at least have a conversation or foundationally have access to some form of T4. And even when I know a person is pre pregnancy planning, especially if they come to us already pre pregnancy planning as a new patient from the very beginning, I want to set them up with a plan that will already easily be carried on into pregnancy, which often does involve some form of long acting T like levothyroxine, synthroid, et cetera. Not always like, but I like to do that. It's, it's handy. Additionally, I like to sort out any progesterone issue because a lot of women have low progesterone when they have thyroid dysfunction. Okay. It is one of the most common hormone depletions that I see in our practice and it happens pretty early on. And progesterone is very important for regulating the timing of your cycle. But for pre pregnancy planning and early pregnancy, it is what largely in a lot of ways reduces our risk for miscarriage. Because progesterone is what keeps our uterine lining intact. It's what communicates to our body that we are pregnant. We need to hold on to that uterine lining, not slough it off and create a period. So what can happen in women with thyroid dysfunction that don't have enough progesterone is they their body will not mount that increase in progesterone quick enough early in pregnancy. They will end up having a period which is actually a miscarriage and that is quite preventable. So on the front end of these women, we want to ensure that they are producing and using enough progesterone. If not, we want to supplement with it. And then also during the pre pregnancy plan phase. I really, really like to give these women an additional form of progesterone at higher levels in a vaginal suppository form so that if they are in fact pregnant, if they get a positive pregnancy test on a Saturday and our office is closed, they can go ahead and empirically start taking it to protect them from miscarriage, especially if they have a history of miscarriage or, or low progesterone. So those are some kind of pre pregnancy planning considerations that we do. I always tell our patients, look, we want to be your second call when you get pregnant. We want to know immediately so that we can begin to address low progesterone and, you know, make sure we're staying on top of your thyroid. Like, sure, you can let your spouse know first, but let us know immediately so that we can most effectively do our job to support you in the best way possible. Let's move from pre pregnancy planning to early pregnancy so this person gets a positive pregnancy test. They let us know what happens next. Immediately. We check a thyroid panel and a progesterone panel. And even at five, six weeks, we actually track that progesterone if it's not sufficient early. We track that every week, so often it's not uncommon. If progesterone's a little low in early pregnancy, again, we will supplement with progesterone. We will put women on a progesterone vaginal suppository that they'll do before bed. And we will actually recheck that progesterone level every week until we feel like it has mounted an appropriate response and the level is safe from a miscarriage risk. Did I say we were neurotic? Yes, we are neurotic, but most women don't mind. I mean, we don't make people do this, but in a lot of cases we feel like it's really necessary just to, if we can prevent a miscarriage due to low progesterone, which is very, very modifiable. We want to do that every time. So even women who go through ivf, the progesterone piece on the back end, we are still neurotic about, because not all IVF practices are as, as neurotic as we are. So every week we check progesterone until we think it is sufficient. If we put women on progesterone, we leave them on it through about week 14 of pregnancy. I must say, of course, none of this is medical advice. This is our approach with Our patients, you need to talk with your doctor or your clinician about your health and your care. There is no one size fits all. Of course. We also check a thyroid panel in early pregnancy as soon as you find out you're pregnant. And then we recheck that thyroid panel every roughly four to six weeks. It's often six weeks. Every once in a while it will be four. If big shifts are changing, we try to stay ahead of any big shifts in demand that your thyroid requires during pregnancy. And checking labs every six weeks really does allow us to stay ahead of those big changes during pregnancy. Research shows that women often need an increase in thyroid medication by roughly 30%. A lot of that kind of takes place in second and third trimesters. So we are very attuned to that. So we're making changes. We're checking labs every six weeks. We stop checking progesterone after week 14 because again, its main role is in early pregnancy miscarriage prevention. We check full thyroid panels, TSH free T4, free T3, reverse T3 and antibodies throughout pregnancy. And let's talk about medication. So in pre pregnancy planning, T3 is very, very important. It's what obviously improves egg quality. You know, egg, everything that has to do with your cycle facilitating your fertility windows is very, very influenced by T3. Obviously not to discount T4, but during the pre pregnancy phase, T3 takes a lot of precedence. We want the foundational aspect of T4 so that when you move into pregnancy, you already have that ready to go. T4 during pregnancy takes priority. And if you guys know me, if you followed me for long, you all know I'm not really a huge advocate for treating a bunch of thyroid patients with Synthroid, with levothyroxine, with T4 only. That is not what we do at modern thyroid clinic. However, T4 hormones are what cross the placental barrier. They are where babies in the womb have access to thyroid hormone and they rely on our thyroid hormone until their own thyroid glands are formed and T3 does not cross the placenta. So it is so incredibly important that the baby has access to T4. I usually like T4 4 ranges during pregnancy to be about 1 to 1.2. Okay, so a little more narrow margins than in my non pregnant women. I do not rely on TSH to tell me what is going on with my patient's thyroid hormones. I don't want their TSH elevated even slightly. Clearly as what's also indicated in research. Right? Certainly the research that we just talked about advocates for a TSH no higher than 1.7. I want someone's TSH closer to 1.1.3. But what happens, especially in early mid pregnancy, is your TSH is very, very influenced by your HCG hormone, so it becomes unreliable. And what's sad is obgyns are still very much using TSH to gauge the thyroid status of their patients, which is not enough, guys. In non pregnant patients, it's not enough. But it is vastly less reliable in pregnant patients. So you need a full thyroid panel. How are we going to know what someone's T4 is if we're not checking? How are we going to know what their T3 is if we're not checking? And their TSH is so heavily influenced by HCG? Not that you can gauge someone's T4 or T3 by TSH alone outside of pregnancy either, but still very, very important. So full thyroid panels all the way is emphasis number one. Emphasis number two. During pregnancy, T4 takes precedence over T3. Inactive hormone is what the baby needs to grow, function, do well. Thrive. T3 does not cross the placental barrier. It is there for the support of the mother. Now let's get a little bit complicated. And guys, this is our practice at modern thyroid clinic. This is not medical advice, okay? You guys will hear over and over and over and over and over again that T3 is contraindicated in pregnant women, okay? And the reason for that is because. Let's talk through it. If you're pregnant and your doctor is checking your TSH and you're taking T3, their immediate thought is, oh my gosh, their T3, suppressing their T4, the baby doesn't have enough thyroid hormones, hormone, terrible things are going to happen. And why are they thinking this? Because they have no idea what your T4 and your T3 are, okay? And they have this assumption that anytime someone is on T3, it will suppress their T4. And again, we cannot have suppressed T4 in pregnancy because that is what crosses the placenta. So, sure. Do we Want to suppress T4 in pregnancy? Absolutely not. Do I honestly ever want to suppress T4 for. From someone taking T3? No. That is not how we practice medicine here. People need access to T4. Do they need too much? No. Do they need too little? No. But they need the right amount, even more so in pregnancy. Okay? And you know how we protect people from suppression of T4 by taking T3? We check their T4 and we check their T3. Right. So none of our pregnant women are walking around with no T4 because they're on T3 because we make sure we check their labs. So very simple solution to this problem. And if we're, if we know, if studies show us in our clinical practice certainly is the same that women need T3 to get pregnant, but they need T4 during pregnancy. Why don't we do both? Right? Why can't women have it all? Why can't they have their cake and eat it too? They can, right? Do we need to be diligent and ensure that women have enough T4 during pregnancy? Yes, we do. Is that possible by frequently checking labs and knowing what you're doing? Yes, it's very possible. So that's that we do use T3 in pregnant women. We prioritize T4. Right. Especially in longer acting forms like levothyroxine, like tyrosine, like Synthroid, especially if people's T4 will not increase enough on something like armor itself. Etc. But it is something we do. I think if you are going to pers pursue a T3 T4 based treatment during pregnancy, you need to have someone that actually knows what they're doing and not any Joe Schmo off the street. Because I do think bad things can happen. I think bad things are happening in non pregnant women because clinicians don't appropriately know how to manage complex thyroid conditions, active thyroid medications, et cetera. And again, I am neurotic about our pregnant women. They need to be managed to perfection. So do I believe in T3 T4 treatment during pregnancy? Yes. Does it need to be done by someone who actually knows what they're doing and that's hard to accomplish? Yes. Also, let's talk about desiccated thyroid in pregnancy. Desiccated thyroid was around for half of a century before levothyroxine was invented. And you know what women took during that half of a century when they have thyroid conditions and they were pregnant? They took armor. So even though it's not been formally tested in pregnancy, it has been used for a hundred years now, literally over a hundred years in pregnant women. So I have no issues with armor in pregnancy. Again, the trick is knowing how to get the patient enough T4 in a stable way consistently throughout pregnancy. And if someone can accomplish that, I feel okay about it. Do I about talk talk with patients about this and say look, T3 is not really used in pregnancy. It's not standard of care. Are you okay if we do it? Desiccated thyroid is not standard of care. Here are pros and cons with each individual patient. Yes we do. Right. Because there is no one size fits all. I'm not making recommendations for your health. Again, you need to talk to your clinician. Deal? Deal. Okay, so again, labs every six weeks, making MET adjustments throughout the entirety of pregnancy. Postpartum. Let's talk about postpartum. Well, let me back up. During pregnancy, antibodies for thyroid, Hashimoto's and Graves usually diminish. Autoimmune diseases tend to go into remission during pregnancy. We become immunosuppressed on purpose so that our body does not attack the baby. Right. And because of that, our antibodies reduce, our inflammation often reduces. And autoimmune diseases are included in that. So what's cool is if you check antibodies throughout pregnancy, you'll usually see them get extremely low. Then we hit the postpartum period and a few things happen. We have patients get labs four to six weeks postpartum. Basically as soon as they kind of come to and are out of this acute haze and fog and not sleeping and just, just total kind of mom mess for a little bit, I know I was absolutely there and the last thing I wanted to think about was going to get labs, etc whenever I got a few minutes without my baby. We get labs four to six weeks after it is a thyroid hormone antibody panel. And what usually shows up is patients need a reduction in T4. Your demand for thyroid hormone increases during pregnancy. Postpartum, that demand reduces pretty quickly. So we need to start reducing T4 substantially. Some other things of note, usually if women are breastfeeding, their hormones are still suppressed. We want to check them nonetheless. We want to screen them for things like postpartum anxiety, postpartum agitation. These things are often fixable. They're often manifestations of low progesterone and can be incredibly life changing and life giving in the postpartum phase. The other thing that happens postpartum is antibodies increase. So while we are pregnant, we're immunosuppressed postpartum, our, our immune system tends to come back in, often with a little overdrive. There are multiple thoughts of why autoimmunity risk is highest postpartum for women. But some are that rebound in immune function, right? Going from immunosuppressed again to hey, I need an immune system again. And it often over exaggerates in that response. The other thought was and is perhaps the DNA of the baby, which is different than our DNA triggers this heightened immune response and attack because it sees it as a foreign invader. So that's another thing. Hashimoto's and Graves both can happen postpartum. It is pretty, you know, in, in the world of Graves it's not an uncommon situation for people to never have a history of GRAVES and to have a transient autoimmune thyroiditis with Graves disease or Graves and Hashimoto's or just Hashimoto's. I find this is usually pronounced even more for breastfeeding moms and it kind of can persist until often women stop breastfeeding and then their bodies sort of recalibrates to its, you know, pre pregnancy state and that autoimmunity will often reduce. Sometimes it even goes away completely. So that's the postpartum period. LDN is one topic that kept coming up in yalls questions. So LDN is not approved for pregnancy. We do not test medication on pregnant women unless it's application absolutely necessary. So LDN is not formally approved for pregnancy, which is not surprising, right? Most meds are not. However, I do use LDN and I have used LDN for probably close to seven years now, maybe even eight in my pre pregnancy planning women during pregnancy. I've used it for infertility, for recurrent miscarriage history. Again, I consent all of these people and we discuss discuss this. Everything in medicine is risk versus benefit. And if the patient decides the benefit is worth it, then we do it. I view LDN as pretty safe during pregnancy and again I use it in people who have a hard time getting pregnant and maintaining pregnancy and have had a lot of success with it. Some people have this hyper aware immune system that doesn't allow people to maintain pregnancy early on. And we saw the stats on autoimmunity and ability to get pregnant, maintain pregnancy and so LDN can really help with that. I used to stop people's LDN around week 32, 34 because LDN in and of itself and I'll have a completely separate episode on ldn, I think I might already have it. If not stay tuned and it'll come out soon. But so I used to have people stop it towards the end of pregnancy because it was blocks, opioids, so pain medication, oral pain medication, anesthesia, in the case of C section, et cetera. I honestly quit doing that about three or four years ago. Never made a difference in pain medication administration, anything like that. It's such a small amount of naltrexone that in the grand scheme of things it wasn't making enough of a difference to stop. And it offers so much protection for that postpartum autoimmune activation that I wanted people to stay on it. So honestly I have people stay on it now. LDN is tested in breastfeeding women at full doses and again this is a microscopic dose of that. So if the full dose is safe, the microdose likely right is safe and it absolutely can help with Hashimoto's, with Graves, postpartum, all of those things. So it is something that I very frequently use. I would use it myself although I'm done having babies thankfully. So yeah can't recommend it enough. I'm going to also now just read through some of yalls questions that you had for me and just rapid fire postpartum anxiety and how it may be thyroid related. It's can't speak to your case but if I was a betting person I would take it to Vegas that it's low progesterone. If you were my patient I'd put you on a a compounded sustained release form of progesterone before bed and it can absolutely completely eradicate postpartum anxiety. How levothyroxine may not help some get and stay pregnant. So getting pregnant, staying pregnant early on is highly related to T3 and progesterone during pregnancy. Again, I value levothyroxine more Same kind of question that goes for if I'm a poor converter. If I don't convert T4, the inactive hormone to T3 effectively how can can that affect my ability to get pregnant? And we talked about that, right? We need T3 when we are pre pregnancy planning early pregnancy when and how to decrease levo after birth. Also is cytomel safe during pregnancy? We touched on that. I really quickly early on get labs four to six weeks later and almost ubiquitously almost every time I reduce T4 how long to be off a GLP before trying to conceive? I got a couple of these questions about GLPs. So the so GLPs, again they are not tested in pregnancy. So you want to stop these. The formal recommendation for women is you stop them 60 days before you are actively trying to conceive. The flip side of that conversation is GLPs influence fertility in a positive way in so many ways. They improve egg quantity, quality, the cycles of your egg, everything, everything almost so so many positive benefits. So that is why we are having an uprise and an uptick in quote oic babies because people are inadvertently getting pregnant because their fertility increases where they weren't getting pregnant before. So the formal recommendation is 60 days. Interestingly y', all for men it is 90 days. So if you are trying to get pregnant and your husband is on a GLP, the recommendation for that is 90 days. That's how long it takes for an entire sperm cycle to be replenished. And so that's why we touched on. Is LDN and T3 safe during pregnancy? Does natural versus C section make a difference in thyroid function postpartum? Not really. I find it to be the same, and I kind of operate with the same standardized procedure. I'm on armor. Do I need to add another medication while pregnant or. Or is this enough? So it is totally unique, right? Like, I'd want the person on armor to have a clinician on board that is very aware of how to use armor effectively in pregnancy. I would say 99.9% of clinicians do not know how to do that. And so that is where my anxiety comes in, because, again, I'm neurotic about pregnant ladies. So if it wasn't us, I'd say if it were, if I was the patient and I wasn't being treated by modern thyroid clinic, I'd probably myself incorporate in some form of levothyroxine. Oh, optimal thyroid levels. Great question. I didn't even bring this in. So pre pregnancy, I want TSH close to 1, can be a little less than 1, can be a little more than 1. Well below 1.8. Okay. And that's also what the study verified. T4, I want between 1 and 1.2, which is a little more narrow margin. T3, I want between 3.6 and 4.2. Throughout the bulk of your day, reverse T3. Pre pregnancy planning, I want 8 to 12. It could be up to 15. However, during pregnancy, y', all, reverse T3 will increase. It is a normal physiological response. Your body is trying to make you lay down, rest and recover. So it is very common almost always to see reverse T3s in the high 20s, 30s, whereas comparatively I see reverse T3 in the 30s, maybe one to two times a month in non pregnant people. So if that gives you a little perspective, we do not treat an elevated reverse T3 during pregnancy because again, it is expected and a normal physiological response. Can elevated T3 make it harder to get pregnant? I'm sure extreme elevations in T3, right, like hyperthyroidism, that kind of thing can also reduce egg quality and amh, et cetera. One of the studies I'll include in the show notes says that now these mildly elevated levels of T3, like 4.8, I mean, I don't have studies to show this, but in my clinical experience, absolutely not. Not at all. Is there a way to prevent your thyroid antibodies from coming back? So ldn for sure, you have to be careful What? You supplement postpartum, but selenium is. I use it in my postpartum patients, influencing how the duration of breastfeeding also impacts antibodies. Why? Reproductive endocrinologists think T3 isn't necessary for egg quality because that is the way that they're trained. No one really trains people in the importance of T3 in pretty much any form or fashion, including endocrinologists. Let's see. Anything else? Why do I feel a thousand times better when I'm pregnant? Probably because your inflammation is reduced, your autoimmunity is reduced. It's interesting how that happens, and it usually is with people who have a heavy inflammatory or autoimmune burden outside of pregnancy. I hope this was super, super helpful, y'. All. I. I did this for one of my absolutely darling patients who is in her postpartum phase, and she's like, Listen, McCall, there is just a. Just not enough information out there about pregnancy. Can you please release some? And I'm like, you know what? I'll do better. I'll do a whole podcast episode dedicated to this. So if you want to recommend what you want me to talk about on this podcast, or guess you want me to interview y', all, please follow me on Instagram. Keep up with my stories, because I ask this stuff literally multiple times a week, every week. So I'll see you there. McCall McPherson, phone. It.