P-36 Hidden cause of decreased fertility rate during Grave's disease

Abstract

Abstract Introduction Thyroid autoimmune disorders interfere with the physiology of reproduction, cause premature ovarianfailure, and mimic the early stage of menopause. Recently, no specific research was made to measure Grave's disease and infertility rates in young patients. Clinical Case Due to an inability to conceive for two years, a 24-year-old Caucasian female was referred to the clinic with typical symptoms and complaints of Grave's disease. She has a family history of Grave's disease and Diabetes mellitus. Ultrasound confirmed the presence of a highly vascularized non-homogeneous hyperplastic thyroid gland. A thyroid scan with Tc99m revealed generalized increased uptake. Laboratory investigations showed a decrease in TSH-!0.005mIU/ml (n.0.4mIU/ml - 4.0mIU/ml), elevated FT4-31.8 pmol/l (n.8.0pmol/l-22.0pmol/l), FT3- 9.69pmol/l (n3.4 pmol/l-6.76pmol/l) and positive Anti-TG -190.05 AU/ml (n>150), Anti-TPO - 75.7 IU/ml (n>75) Anti-TSHR-27.3 IU/l (n>1,5). Prolactin and gonadal hormones were within normal limits AMH - 1.8 ng/ml(n1.52ng/ml-9.95ng/ml), Fsh- 6mIU/ml(n3.9mIU/ml-12.4mIU/ml). The patient was started on Methimazole and Beta-blocker. While decreasing the Methimazole dosage for further discontinuation, disease recurrence developed, and a total thyroidectomy was performed. Post- operatively, the patient was maintained on Levothyroxine. After 6 months of follow-up due to irregular Levothyroxine intake, the patient reached a hypothyroid status, during which, the patient had 2 consecutive spontaneous pregnancies, from which, one ended with spontaneous miscarriage in the early weeks of pregnancy and another, ectopic pregnancy treated with right salpingectomy. HSG confirmed weak left fallopian tube patency. After several months of keeping TSH below 2.5 mIU/ml, IVF treatment was scheduled. The results of the infertility workup showed a decrease in ovarian reserve AMH - 0.163ng/ml (n1.52ng/ml-9.95ng/ml), Fsh-16.23 mIU/ml(n3.9mIU/ml- 12.4mIU/ml), due to it, modified natural cycle IVF was performed. She received 2 oocytes and 2 embryos. One high-grade blastocyst was transferred in a fresh cycle that ended with pregnancy and delivery. The child was born without a genetic disorder but with natal teeth. Conclusion This is a rare case of infertility with diminished ovarian reserve due to Grave's disease. A pregnancy was reached by proper correction of thyroid hormonal parameters and modified natural cycle IVF. It indicates a possible need for close monitoring of the functional ovarian reserve in patients planning pregnancy even at the young age group.