Advice regarding infertility, autoimmune hypothyroidism and ferritin results of 11

[Landlubber]

Hi everyone,

I would appreciate any advice (paticularly around fertility) following my recent test results.

To give some context, I am 33, my partner is 37 and we have been trying for a baby for 2 years and 9 months. We did fall pregnant in December 2022 (after 10 months of trying). Unfortunately, this pregnancy ended in a miscarriage at 9 weeks. I was referred by the GP to gynaecology in March after just over 2 years of trying to get pregnant with no other positive pregnancy tests. Blood tests appear to show I'm ovulating, have good ovarian reserve and I've had normal transvaginal ultrasound and HSG results. My partner's sperm test came back as normal.

The gynaecologist confirmed that I have an underactive thyroid in May (serum TSH level: 5.230 mU/L, normal range 0.570 to 3.600, serum free T4 level: 7.7 pmol/L, normal range: 7.9 to 14.0), after two previous results that were classed as subclinical hypothyroidism by the GP (the GP was managing this conservatively). My underactive thyroid was found to be autoimmune (thyroid antibodies TPO: 729.3 U/mL, normal range:

0.0 to 9.0).

The gynaecologist started me on 75mcg of levothyroxine. My levels were tested again in August 2024 and the GP said these are now normal (serum TSH level: 0.173 mU/L, normal range: 0.570 to 3.600 pmol/L, serum free T4 level: 14.3, normal range: 7.9 to 14.0) and so I have remained on 75mcg. I am aware these are now below normal levels but am unsure how this affects health and fertility? I have never been tested for T3 levels.

The gynaecologist referred me to endocrinology to further investigate and advise on the fertility issues. The endocrinologist retested my thyroid and tested various other hormone levels a couple of weeks ago. I am still awaiting the results of these tests. I am unsure if the endocrinologist has retested antibody levels.

I have had a reduction in some symptoms after starting levothyroxine but lots have persisted. I will list them all below:

Persistent fatigue

Recurring stomach pain (appears to be getting worse recently. I've had this every day for past 2 weeks, especially after eating)

Bloating

Painful gas (frequent flatulence and burping, regular gurgling stomach)

Acid reflux and regular hiccups after eating

Occasional mucus and undigested food in poo

Frequent nausea (worse before/during period)

Problems with bowel moments for years, often they are loose but sometimes they are hard to pass (I have previously been told by the GP I have IBS)

Haemorrhoids (have had them over a year) which sometimes bleed and don't respond to treatment

Frequent bowel movements (3-4 times a day)

Dizziness/light-headedness, sometimes accompanied by blurred vision (previously occasional vertigo but the vertigo appears to have stopped after starting the levothyroxine)

Sometimes it briefly feels as if the floor is moving

Constant tinnitus

Hearing loss in both ears (confirmed by hearing tests, severe at high frequencies and borderline at mid frequencies)

Joint pain (mainly knees and elbows)

Recurrent low mood and anxiety

Occasional restless legs (better recently, after starting levothyroxine)

Recurrent itchy skin (better recently, after starting levothyroxine)

Regular headaches (better recently, after starting levothyroxine)

Infrequent urination

Sometimes I have pain during and after sex

Muscle cramps in legs (especially when in bed)

Brittle nails

Recurrent mouth ulcers and painful tongue and roof of mouth

Problems with regulating temperature (often feel very cold but other times very hot)

Dry eyes (confirmed by the optician)

Occasional heart palpitations

Occasional tingling and numbness in hands (appears to be better after starting levothyroxine)

Lots of and easy bruising

Pale skin

Issues around periods:

Leg pain

Back pain

Heavy periods and often lots of clotting (the period before last I had flooding & passed some very large blood clots)

Slightly irregular periods, ranging from 24-36 days (this has stabilised since starting levothyroxine but it may be too early to tell)

The digestion/bowel problems are worse before and during my period

I have been seen my ENT for the hearing loss, tinnitus and dizziness/vertigo. They have carried out a few tests but can not find a cause so far. Some of the consultants have mentioned carrying out an MRI but this not yet happened. At my most recent appointment in August, they said this is probably thyroid related. However, the dizziness/light-headedness has continued despite starting levothyroxine in June. (However the vertigo appears to have stopped.)

After reading advice on here, I have cut out gluten, dairy and caffeine to help reduce my antibody levels. I started this in July. I have also cut down on alcohol and soya (there have been a few occasions where I have consumed some) and don't smoke. My partner has also cut out caffeine and drinks alcohol infrequently. I am also vegetarian. I have tried to improve my diet as much as possible.

After reading other advice on here, I also asked the GP to test B12, Vitamin D, folate and ferritin levels a couple of weeks ago.

These came back as:

Serum ferritin: 11 ug/L

Normal range: 11 to 307

Serum 25-HO vit D3 level: 40.4 nmol/L

Normal range: above 50.0

Serum vitamin B12: 246 ng/L

Normal range: Above 203

Serum folate: 17.6 ug/L

Normal range: above 4.0

The GP text me to advise me to take a Vitamin D supplement (but not what dose to take) as my levels are slightly low. My main concern is my ferritin levels, which they are classing as normal and so they have given me no further advice on this. However, after some research, they appear to be suboptimal and the laboratory comment under the test results on my NHS app states, 'If result is less than 14 ug/L, iron deficiency is likely'.

I have also read some posts on the internet stating a B12 level of less than 500 is suboptimal?

I have previously had a full blood count in February 2024. The results were all 'normal' and seem to confirm I did not have anemia at the time.

The results were:

Haemolglobin estimation: 126 g/L

Normal range: 115 to 165

Haematocrit: 37.2 %

Normal range:

36.0 to 46.0

Mean corpuscular volume: 81.7 fL

Normal range:

77.0 to 100.0

Mean corpusc. haemoglobin (MCH): 27.6 pg

Normal range:

27.0 to 32.0

Mean corpusc. Hb. conc. (MCHC): 338 g/L

Normal range: 315 to 345

Red blood cell distribut width: 13.1 %

Normal range:

11.6 to 14.0

lymphocyte count: 2.6 x10*9/L

Normal range:

1.0 to 3.0

I feel like it is a battle for my GP to take my problems seriously and this is getting me down. My fertility problems are taking a toll on my mental health and this is not helped by my other symptoms (especially the constant fatigue).

I have found the gynaecologist very helpful but I have only seen him once in person and am now waiting for my next appointment, with no indication of how long this will be. The gynaecologist has previously advised the next step would be a referral for IVF (this was before the ferritin results came back) but if I there is any action I can take to help increase my chances of getting pregnant and supporting a pregnancy naturally I will take it.

I am going to talk to him at the next appointment about testing for endometriosis, as this is something I have wondered whether I may have.

Please can anybody give me some advice on how to proceed, especially following my recent ferritin test results and any other advice in general regarding my symptoms and improving my fertility?

Thank you very much for reading this long very post! I am grateful for any help.

[humanbean]

Low levels of nutrients are very common in people with thyroid disease. In hypothyroidism the low nutrients are usually attributed to reduced stomach acid meaning that your gut will struggle to properly digest your food and extract the minerals and vitamins you need.

So people like us usually end up rattling from all the supplements we take.

.

Your ferritin (iron stores) has been declared to be normal at a level of 11. This is disgraceful. If you were to look up iron deficiency and hypothyroidism you would find that many websites recommend a ferritin level of 90 - 110 micrograms/L, or somewhere close to that.

Take a look at the following link from NICE (National Institute for Health and Care Excellence - a UK government organisation), and note that NICE thinks a ferritin result below 30 micrograms/L confirms iron deficiency :

cks.nice.org.uk/topics/anae...

Serum ferritin level is the biochemical test that most reliably correlates with relative total body iron stores. In all people, a serum ferritin level of less than 30 micrograms/L confirms the diagnosis of iron deficiency. However:

Ferritin levels are difficult to interpret if infection or inflammation is present, as levels can be high even in the presence of iron deficiency.

Ferritin levels may be less reliable in pregnancy.

A lot of doctors ignore low iron or iron deficiency if the patient is not anaemic, and they determine that by looking at haemoglobin. Your haemoglobin is 120+ so you are not considered anaemic. It is quite common for iron deficiency to develop a long time before a patient becomes officially anaemic, but that isn't an excuse for ignoring low iron. It needs to be treated. And the added benefit is that treating iron deficiency often avoids making the patient anaemic.

If your doctor isn't going to prescribe iron supplements for you, then be aware that it is possible to treat an iron deficiency without prescription, but you need to take the "good" supplements, not just something from a supermarket which will be incredibly low dose. There are several ways of raising iron, and different options suit different people as tolerance can be an issue with iron.

Please note that raising iron and ferritin levels is often very slow - it could take many months. And even when you have succeeded in raising your iron and ferritin you may still need to take a maintenance dose.

It is a good idea to get an iron panel done before starting iron supplementation. It sometimes happens that people with low ferritin also have high serum iron. And when such people supplement it can lead to ferritin staying low, but iron just keeps on rising. This is definitely something to be avoided. There are ways and means of overcoming this but I can't write about them now. It's the middle of the night.

This will need to be fleshed out but I want to go to bed...

Vitamin D is considered optimal for us when it is about 100 - 150 nmol/L.

Your B12 is also appalling. It would be best at the top of the range (if there is one), or at about 1000 ng/L.

See these links on supplementing B12 and optimal levels :

perniciousanemia.org/b12/fo...

perniciousanemia.org/b12/le...

perniciousanemia.org/b12/le...

Quite a few of your symptoms might be caused by low nutrients rather than by your hypothyroidism, but you'll just have to supplement to find out what symptoms go away.

I'll try and come back and fill in the gaps tomorrow afternoon.

[Landlubber in reply to humanbean]

Thank you so much for taking the time to reply. I am very grateful. I know it was a very long post so didn't expect anybody to reply but I was up in the early hours worrying and feeling anxious so just needed to get it all down.The information you've provided is incredibly helpful. It makes me feel validated and less 'crazy' for everything I've been experiencing. It gives me a starting point to make a plan to begin to get better. I just wish the GP could have listened to me in the way you have.

Thanks again for your kindness and expertise.

[Tina_Maria]

So sorry to hear that you have been feeling so unwell. It is a constant battle with the GPs, as they do NOT listen to their patients. Here are a few thoughts:

TSH 0.174 (0.57 - 3.6) T4 14.3 (7.9-14)

Your TSH is a bit below the reference range and your T4 is right on top. Sadly, they have not tested your T3, as this shows the active thyroid hormone, which you are converting from the T4 you are taking. I suspect that your T3 levels are low, hence you continue to have symptoms. Could you try to do a private blood test for your thyroid function? If you measure TSH, T4 and T3, you could get a better picture of where exactly your levels are. Thyroid UK offer a 10% discount on private blood tests, so it is worth considering. And don't agree to lower your dose at present, before you know what's happening with your T3, as this may worsen your symptoms.

Your iron is far too low, especially as you have heavy periods (lots of iron stores lost there), anaemia will make you feel very exhausted. Heme-iron (found in animal products) is most readily absorbed. The best thing would be to supplement, as you most likely will have absorption issues like many hashimoto's patients. I think the Three Arrows iron supplements are recommended here.

Not sure if you are aware, but folic acid (Vitamin B9) is not well absorbed, so even if you have taken it before, your body may not have had enough stores. Best forms of getting Vitamin B9 is in the form of methyltetrahydrofolate, which is readily absorbed by the body. Igennus (available on Amazon) do a great Vitamin B complex with all the essential B-vitamins including folate. You can take 2 tablets a day at the beginning to get your levels up and then move to one a day, once you feel better.

Your Vitamin D is also too low, good levels should be nearer 100 nmol/L. If you take doses that are too small, they may be insufficient to top up your stores. You also may need to supplement all year round (especially in the winter). I would start with 3000IU, many Vitamin D3 supplements now come with Vitamin K2 as well, which is important, as the Vit K2 directs the calcium to the bones. Do you take a magnesium supplement? Also important for energy, as many people are deficient. If you take it with the Vit D3 supplement, it also helps with the absorption. Avoid Magnesium oxide, as the body cannot absorb it easily, good forms are Magnesium citrate (can be laxative at high doses), magnesium glycinate, magnesium taurate or maleate.

It's a lot of information at the beginning, but don't despair, you will get there; just take it one step at a time.😉

[Landlubber in reply to Tina_Maria]

Thank you so much for your help and for providing all this incredibly useful information. You're right, it's all a lot to take in at the moment but I'm feeling better now you and humanbean have given me a plan to go forward.

[humanbean]

To add to the information I gave you in my earlier reply...

To get an iron panel done, hopefully your doctor would order this for you, but if they don't you can get one done privately. It requires a finger-prick sample of blood, but if you know someone who can take a venous blood sample for you this is probably better. It is possible to pay for a phlebotomist to take blood but if it can be avoided it cuts costs.

medichecks.com/products/iro...

For a discount code :

thyroiduk.org/testing/priva...

If you register with Medichecks (it's free) they will send you an email with other (higher) discount codes when they have sales.

Blue Horizon is also worth registering with too, for the same reason.

Note that taking biotin can corrupt some blood tests, but unfortunately it is not possible to know in advance if a particular test will be affected. So we always suggest stopping taking any supplements containing biotin for a couple of day before taking blood. If the dose you take is particularly high then you should stop taking biotin for 5 - 7 days.

Reasons for avoiding biotin before testing are discussed in these links :

healthunlocked.com/thyroidu...

healthunlocked.com/thyroidu......

...

For info on iron supplements...

When doctors prescribe iron supplements they usually prescribe one of the following iron salts :

ferrous fumarate 210mg --- bnf.nice.org.uk/drugs/ferro...

ferrous sulfate 200mg --- bnf.nice.org.uk/drugs/ferro...

ferrous gluconate 300mg --- bnf.nice.org.uk/drugs/ferro...

All the above can be bought at pharmacies without prescription with a pharmacist's permission. They aren't very expensive, and brand doesn't matter. Expect to be quizzed about your need for it. I just tell them my ferritin levels are low and my doctor told me to buy my own supplements.

Very few people tolerate ferrous sulfate, so avoid it.

I took ferrous fumarate 210mg for a very long time, but I could only tolerate it with food which probably reduced my absorption quite substantially.

I've never taken ferrous gluconate but others on the forum have.

Iron salts of all kinds are suitable for vegans, as far as I know, but always check for yourself.

...

Another form of iron supplement are ones containing heme/haem iron. They are not suitable for vegans or vegetarians but as iron supplements go, for many people they are easily tolerated, and are more successful at raising iron than iron salts for many people.

healthunlocked.com/thyroidu...

threearrowsnutra.com/en-uk/...

...

If you want to raise your iron the fastest way possible then you could investigate getting an iron infusion. I've never had one of these, but there are clinics around the UK that will treat people privately.

...

Vitamin D comes in two forms, D2 and D3. Ignore D2, and take D3.

Note that Vitamin D3 is usually sourced from lanolin in sheep's wool, but there are D3 supplements available that are made from lichen. I've never bought one myself, so you'll have to do your own research. I don't know how many brands are available.

wellbeingnutrition.com/blog...

For info on how to dose vitamin D supplementation, see this link :

grassrootshealth.net/projec...

To test your vitamin D alone (it's usually cheaper to buy a test bundle which includes vitamin D) :

vitamindtest.org.uk/

...

I mentioned B12 yesterday and gave you links on the subject, but I forgot to mention folate which is required for the body to metabolise vitamin B12.

A lot of reference ranges for folate have no upper level, so I aim to get mine to 20 micrograms/L.

Doctors usually prescribe folic acid to women wanting to get pregnant, and they prescribe absolutely massive doses. Folic acid was first developed in 1943. Before 1943 all humans got their folate from their diet. Many articles on the web and even some research papers confuse folic acid and folate, switching from one name to the other, and it is very confusing.

About 50% of the global population don't have the right genes to metabolise folic acid into methylfolate at all or not very quickly. Instead of folic acid the better supplement is either methylfolate or folinic acid. These two supplements are metabolised properly by everyone, whereas folic acid isn't.

drfuhrman.com/blog/16/why-y...

methyl-life.com/pages/methy...

pnas.org/doi/full/10.1073/p...

web.archive.org/web/2024022...

chriskresser.com/folate-vs-...

One thing I have found is that I can't hang on to folate very well, so I have to supplement with methylfolate in quite high doses several days of the week. I think this is fairly common. Folic acid, on the other hand, gets stuck in the blood stream and makes blood tests for folate look artificially good.

There are more B vitamins than just B12 and B9 (folate). So when you supplement either or both of these it is strongly recommended that you also take a B Complex product. I'm not sure what B Complex people are currently taking, so it would be worth asking in a new thread.

Good luck.

[Landlubber]

I can't thank you enough for how helpful you've been! I'm so glad to have a plan to go forward from you and Tina_Maria. The information you've provided is absolutely invaluable. I was getting very overwhelmed and confused by Googling! I managed to get hold of gynaecology and they have given me an appointment for Friday so I'm going to ask him about doing the iron panel, as he's been helpful so far.