benefits of bariatric surgery to become evident including optimum weight loss and metabolic stability. The recommendation is to wait at least 12 months before planning to conceive unless there were convincing reasons to act early such as advanced female age with low ovarian reserves.
References
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13 The patient with thyroid disease
Shiao‐yng Chan
Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Case History 1: A 35‐year‐old woman with unexplained infertility is about to undergo IVF treatment. She has been diagnosed with hypothyroidism 2 years ago. She has maintained normal thyroid function test results with levothyroxine 100 μg/day for the past 18 months and has been clinically euthyroid. Her most recent test showed a thyroid stimulating hormone (TSH) level of 3.8 mU/L (normal range: 0.4–4.2 mU/L) and a free thyroxine (T4) level of 12.2 pmol/L (9.5–20 pmol/L).
Case History 2: A 26‐year‐old woman was diagnosed with Graves’ disease 6 months following the delivery of her only child 4 years ago. After 2 years of carbimazole treatment her disease became quiescent but recurred 6 months ago. She is currently on carbimazole 30 mg/day and is clinically euthyroid with a small soft diffuse palpable goiter. She has been with a new partner for the last 2 years and would like to proceed with ICSI for male factor infertility. Thyroid function tests performed within the last month showed a TSH level of 0.03 mU/L (0.4–4.2 mU/L), free T4 of 18 pmol/L (9–20 pmol/L) and free T3 of 6 pmol/L (3.5–6.8 pmol/L).
Background
The management of women with thyroid disease preconceptually and during pregnancy is a clinical area that is advancing rapidly. Recommendations are being refined as new evidence continues to emerge. Several controversies, including those surrounding the universal screening of pregnant women for thyroid disease, thresholds at which treatment should be commenced in newly diagnosed subclinical disease and whether to treat euthyroid thyroid peroxidase (TPO) antibody positive women, remain unresolved even after results have emerged from recently completed clinical trials. Updated clinical guidelines by different professional bodies have been published but the consensus opinions expressed are not identical [1,2]. Thus, there are differences in the specific management strategies adopted by various centers, but the general basic principles are broadly similar. It should also be noted that reference ranges for thyroid function tests vary according to the laboratory assay, ethnicity of the population and stage of pregnancy.
Hypothyroidism
In iodine replete countries, the incidence of hypothyroidism diagnosed before pregnancy is about 1%, the commonest cause being primary thyroidal failure due to autoimmune thyroiditis. In addition, approximately 2.5% of pregnant women have subclinical hypothyroidism, defined by an elevated serum TSH concentration but normal free T4 and free T3 concentrations [3]. This can be indicative of the early stages of thyroid insufficiency or inadequate thyroxine replacement in previously diagnosed overt hypothyroidism. Worldwide iodine deficiency remains the leading