ATA Guidelines Tools

15 Box 2. Practical Considerations for Managing Thyroid Dysfunction in Women With Infertility or Undergoing Fertility Treatment • It is advised to reassess the patient's fertility treatment plans and schedule (e.g., ovarian stimulation and embryo transfer) at each visit because these can change throughout the fertility treatment pathway, and these changes may require adjustment of thyroid treatment and/or follow-up planning accordingly. • There are substantial changes to thyroid physiolog y during fertility treatment, in particular during ovarian stimulation (Figure 1A), which may make interpretation of thyroid function tests more difficult. Therefore, it is sensible to refrain from obtaining thyroid function tests during ovarian stimulation or within 2 weeks of an ovulation trigger. • In women on levothyroxine, increases in estrogen from ovarian stimulation can lead to an earlier increase in levothyroxine requirements compared to in women who conceive naturally. The extent of estrogen increase and levothyroxine requirements are partly determined by the duration and intensity of ovarian stimulation. It is reasonable to anticipate this physiolog y and check thyroid function tests two weeks after a positive pregnancy test. • The majority of thyroid dysfunction in women with infertility and/or planning fertility treatment is identified through a routine work-up for the underlying cause of fertility treatment. Therefore, it is more likely to detect a latent phase of disease, which may present in an atypical manner as compared to patients who present with symptoms. • Thyroid function testing should be assessed upon presentation of thyrotoxic symptoms in women undergoing fertility treatments, as painless thyroiditis and Graves' disease may be induced by gonadotropin-releasing hormone analogues or following a miscarriage. Recommendations Table 4. Thyroid Function Testing and Monitoring in Women With Infertility Strength * Level # TSH testing should be performed in all non-pregnant women who present with infertility or recurrent miscarriages. Good Practice Statement TPOAb testing may be performed in all women who present with infertility or recurrent miscarriages. Conditional Low For women with infertility or recurrent miscarriage who are taking levothyroxine, utilize a target TSH of 0.5–2.5 mU/L preconception and in pregnancy. Good Practice Statement For women using levothyroxine, TSH may be checked once within 6–12 weeks prior to controlled ovarian stimulation, approximately two weeks aer a positive pregnancy test and then according to pregnancy recommendations (see elsewhere). Conditional Low * Strength of Recommendation; # Level of Evidence; Good Practice Statement. Thyroid Dysfunction and Infertility

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