Wednesday, August 28, 2013

A post on endocrinology, and need all your inputs about something else

First, lets get the pregnancy-related news for the day: The betas doubled appropriately, going from 661 on day 17 to 2329 on day 20.

About thyroid in pregnancy and the state of affairs in India: 
According to the studies coming out in the recent years a Thyroid Stimulating Hormone (TSH) value of over 2.5 is considered unideal for pregnancy, and is managed by giving patients a small dose of thyroid hormone(T4), and then checking the TSH, T4, and T3. The endocrinologist I saw in New York (Robert Lind, who presented with the trifecta of perfect qualities in a physician (approachabilty, keeping up with literature, and sensibility), followed the practice of keeping my TSH well below 2.5 during pregnancy. The endocrinologist I saw in San Diego also followed this practice.

Shannon, I'd love to get your take on the overall policy in the US overall about this. 

Unfortunately, doctors everywhere are resistant to change; I think they get convinced of a new practice  if they a) read a study and everybody is talking about it or b) go to a conference and a large number of their peers endorse the idea. It is only a small percentage of doctors who actively innovate as opposed to doing it by the book.

Hence, while the TSH normal range adjustment has taken in the US (enough people talking about it), it is going to take much longer to come to India. Overall, I think doctors and practices here are around 5 years behind the West, where all new ideas first most often come, which is a seriously depressing thought.

I came up against this today:It took 6 emails for my RE to give me the TSH value, which he pronounced as "normal."

When he finally sent it to me, it turns out to be above 2.5; 2.77 pre-pregnancy. Which means it will likely go above 3 during pregnancy. Ideally, it should be managed by prescribing thyroid hormone (T4) and then checking the values regularly.My RE flat out refused to do this, and  unfortunately, I think I would have a difficult time convincing endocrinologists here to do it, and I may have to manage J's thyroid levels myself (it is easy and straightforward) but still, I should not be having to do it, because I'm not a doctor. It really sucks that I have no choice.

Overall, not a good testament for medicine in India.

Infertility consulting?

Every now and then, I get an email from somebody asking for advice/help about what to do.  I realize I have a lot to offer, from explaining the treatment path options, informing them of their choices, picking doctors, looking up options (for example, finding the one place in India that provided PGD options; that was not easy), and helping them process what their doctor is telling them, and helping them figure out if their doctor is good or is taking them for a ride.

Basically, act as a consultant and get paid something for it. I would probably start out by maybe charging a 100$ per case (a flat fee).  Before I flesh this idea out any further, I would love feedback about how viable this is. Please be as honest as you want to be; what I''m really trying to figure out how many people would be up for paying a little bit more ( a drop in the bucket compared to what they pay for infertility treatments) for this.

Any business/legal advice about the feasibility of this would be welcome as well.


  1. Jay, my pre-pregnancy TSH level was 3.5, now a week before it is 0.88 with the same dosage of thyroxine. What do you think about it ? When I had my TSH levels close to 1, I didn't conceive. Have you any knowledge about publications which talks about body increasing its TSH during pregnancy ? I am really sorry that you are smitten by US ways of dealing things ( mindless therapies and treating values on papers ) I am so happy that our RE is logical enough to refuse your request. Numbers on paper and some low impact factor scientific papers doesn't mean anything. For a doctor the most important quality is logical reasoning power and I am sure our RE has lots of it. Do not forget that experience matters at the end. Just because some REs treats numbers on papers it doesn't mean they are sensible and knowledgeable. Any RE, why an RE, any person who can read and understand scientific papers could suggest what you say - blindly increse TSH by providing thyroid supplementation if it is below 2.5 (total nonsense !) I have already provided you a reference for a large scale study which says that sub-clinical hypothyroidism doesn't really affect the chance of conceiving nor does it increase the chance for miscarriage. I'm sorry that you are so naive - you don't care about your REs experience but believe papers whose results are based on too few study subjects.

    What you have talked about in the last para is about patient advocacy and functioning as a patient advocate. It is a wonderful field. Knowledge alone is not enough, a good PA should be empathetic, must possses good logical reasoning power and must practice humility so that he/she gets an open mind to learn different things. Good luck ! It is a great profession which will give immense emotional satisfaction.

  2. Manju: your reasoning is not linear: TSH has no well-established (to my knowledge) effect on conception, and I never said it did. And yes, there are many many studies which show that the body increases TSH during pregnancy, which is then accompanied by a very required increase In T4, which can then suppress TSH through feedback, if necessary. This part is complicated though, especially in women with thyroid disorders.

    I am aware of studies that show no association between higher TSH levels during pregnancy and adverse outcomes. I am also aware of the multiple studies which show the opposite: a slight association between higher maternal TSH levels during pregnancy and 2 things: an increased risk for miscarriage and slightly lower offspring IQ. This is an area of very intense study, and the results are conflicting. Of course I know that.

    When there are 2 sets of studies showing conflicting results, it would be best (in the opinion of many) to err on the side of caution: giving low dose T4 if TSH levels are above 2.5 during pregnancy is easy and has been shown to do no harm. This is the policy that REs are adopting in the US, and its a logical one. So the best thing to do would be to retest TSH and proceed accordingly.

    As to your diatribe: I am not in agreement with with many of the conclusions that both you and Dr. Malpani have reached on many, many things, but I have both the sense and the manners not to try to force my conclusions and opinions on you, and certainly not in such a confrontational manner: All I want is to be able to do what I think is sensible and err on the side of caution in my own situation, and I most certainly have a right to that.

    You are in a delicate state right now, you have no need of such drama, and nor do I. So please, let us say no more on this topic.

  3. Jay, I emailed you, but had to comment here, especially after reading Manju's comments. First, I don't think Manju really understands the subject - or perhaps I'm misreading, because it sounds as though she's saying that thyroid supplementation increases TSH? I admit I got a little confused by what exactly she was trying to say.

    But as an endocrinologist myself, I welcome educated patients asking me intelligent questions, sharing studies with me and pushing me to do further investigations and even possibly improve my own practice. I admit, it irritates me when patient's who have read one article on some no-name website want to argue with me, but even then I try to listen to what they have to say. It's part of being a good doctor - and it's why it's called the PRACTICE of medicine, because we're always learning and always changing as we learn. Or we should be. There is NOTHING wrong with questioning your doctor - and over the years I've seen quite a few incidences of major crisis being averted because a patient questioned their doctor. (My own's son's cancer was only diagnosed because I insisted on a referral - my doctors, who I trust, tried to reassure me that all was well.)

    But I do want to reiterate the Endocrine Society guidelines for management of hypothyroidism in pregnancy. These guidelines take years to come out, and are hotly debated by the committee that writes them (after many studies are reviewed), and then by the endocrine community at large before being published. These guidelines are written by the top thinkers and leaders in the field, and they know what they're talking about. They feel the evidence for adverse obstetrical outcomes in women with subclinical hypothyroidism AND positive TPO antibodies is strong enough to warrant treatment with thyroid hormone supplementation (levothyroxine). They also agree that women with subclinical hypothyroidism without positive TPO antibodies have not been shown to have adverse outcomes. There's a clear difference between women with TPO antibodies and those without, and perhaps that's where some studies have failed to consistently show risks with subclinical hypothyroidism, because they haven't distinguished between the two groups.

  4. Jay, I am not making any drama. I'm pregnant and it doen't mean I'm like a glass you said in a delicate state (It's a shame that you said so !) . A good scientist enjoys arguements and tries to learn from that.
    When a woman has thyroid antibodies there are lots of chances that her TSH increases during pregnancy. It is totally not logical to put a woman on thyroid, that too a surrogate based on the microdifference you found on the lab report !
    As usual it is very difficult to argue with people who "know it all" ! Good luck !

  5. Shannon, I stand corrected, I should have said that TSH decreases. It doesn't mean I am naive about the subject and as an endocrinologist you know well that such increase, decrease confusions are very common when talking about TSH and you also know very well what I really had in my mind ! I agree what you have said about in the last para of yours. It entirely depends on the TPO antibody status of the patient. I am not saying you should not question your doctor but it is not necessary to compare US doctors with Indian doctors. It appears so sick and this is not the first time I am seeing such comparisons ! I am a biologist, a researcher and I am not talking here by reading one article or no-name website. Don't scratch each others back - it is always better if an endocrinologist like you and a scientist like Jay could be a little humble and not make people who is trying to say something appear like a fool !

  6. Dear Jay,

    I don't think it's fair to say Indian doctors are 5 years behind the West. You seem to think that whatever is the latest is the best. However, new is not always better - and we have seen lots of "fashions" come and go. We'd rather be conservative and practise evidence based medicine, when there is enough evidence to show that we need to change.

    It's better to have a doctor who is conservative who sticks to time tested principles, rather than one who "innovates" by using their patients as guinea pigs

    Remember the Physicians Prayer -

    From inability to let well alone,
    from much zeal for the new and contempt for what is old,
    for putting knowledge before wisdom, science before art,
    and cleverness before common sense,
    from treating patients as cases and for making the cure
    for the disease more grievous than the endurance of the same,
    good Lord deliver us. - Sir Robert Hutchison.

    Dr Aniruddha Malpani, MD
    Malpani Infertility Clinic, Jamuna Sagar, SBS Road, Colaba
    Bombay 400 005. India
    Tel: 91-22-22151065, 22151066, 2218 3270, 65527073

    Helping you to build your family !

    You can add a google review for us at

    My Facebook page is at

    You can follow me on twitter at

    Watch our infertility cartoon film at

    Read our book, How to Have a Baby - A Guide for the Infertile Couple,
    online at !

    Read my blog about improving the doctor-patient

    relationship at

  7. Dr. Malpani: I want aneuploidy testing; I don't want it because it is new, but because it decreases the risk of BFNs and miscarriage. It also decreases the need for amnios. It also prevents people from having a baby with an aneuploidy. It prevents you from having to transfer multiples, and live with the consequences of things going mildly wrong: for example, twins often come a bit earlier; even a slightly premature birth can detrimentally effect the health of the child.

    People are able to provide it through trophectoderm biopsies and CGH microarray, and those who do it are not "jumping on the bandwagon" as you once put it; they are trailblazers, and I'm very glad they exist.

    I want intelligent TSH testing. I want my doctors to be well informed about the studies available in this area.

    I want great NICUs. My mom who is familiar with NICUs in America and India, and she begged me to have my baby (during my 3rd short-lived pregnancy) there based on the disparity, and she belongs to the Indian medical establishment.

    I want the capacity to do a maternal blood test to rule out Trisomy 21 and other aneuplodies. That technology is probably years away in India, but is available in the US and in Hong Kong.

    These are "new" yes, but I don't want them because they are new, and I should not have to justify I want them, it should be obvious. In other words, there is a rationale to everything I "want;" I think to dismiss the usefulness of these technologies or the people that offer them, or my thought process in wanting these is not the best way to go, but that is your call entirely.

  8. Thanks Shannon, all of that is very useful (and rational and respectful), and I'm glad it is out here.

    Basically, what I inferred from the last bit is that is that if you have a high-ish TSH value, the prudent course if to test for anti-TPO antibodies and TSH during pregnancy, and make the call on how much (if any) T4 to treat with based on that, and that is what I will have done for the surrogate.

  9. A good scientist does enjoy debate, but would require that the person that they be debating with was courteous, stuck to only the facts and did not get personal. They would also like the person they were talking to to be well informed, and present their facts in a calm, well thought out manner. That is the only sort of debate I would welcome or allow on my blog, which is my personal space.

    This tone is definitely not one that I would choose to retain on my blog, and we do not need to continue this; it takes us both nowhere.

    I am hence locking comments on this thread.