Pregnancy risks for female MDs

I just saw a note from “Medscape”, entitled
“Female doctors have higher infertility rates and pregnancy risk: what can be done?”

Would delivering a baby by cesarean section stress you out? Lady surgeons do it all the time!

A quick search revealed the paper, “High infertility rates and pregnancy complications in female physicians indicate a need for culture change”, by Krista Lai ¹ , Erin M Garvey ¹ , Cristine S Velazco ¹ , Manrit Gill ² , Erica M Weidler ¹ , Kathleen van Leeuwen ¹ , Eugene S Kim ³ , Erika L Rangel ⁴ , Gwen M Grimsby ⁵
PMID: 36250327. DOI: 10.1097/SLA.0000000000005724

Equally alarmingly, Rangel said: “medical trainees appear to have almost as high a rate of pregnancy complications as surgeons who have already completed their training. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.”

OPINION

I find the statement that “Female doctors have higher infertility rates and riskier pregnancies” not in the slightest remarkable. Nor is the corollary statement, “Medical trainees have almost as high rate of pregnancy complications as surgeons who have already completed the training”, surprising. To my mind, there is an explanation for the problem and perhaps, a solution.

EXPLANATION

Without going into deep, unnecessary and perhaps confusing detail, the facts are as follows:
(1)The medical profession and particularly the surgical branch of the profession, is well known for high stress: Many of us “ride out” our chronic stress for years or decades, never realizing that although our inflated self-confidence allows us to look (and even feel), unstressed, our subconscious stress level is huge. Unrecognized and untreated stress accounts for the fact that medical doctors’ suicide rate is “number one”.
(2) Female trainees, in a course with a reputation for the steepest of learning curves, in competition with their male peers in a reputedly male-dominated, risk-prone profession, are stressed by definition.
(3) Stress increases cortisol production.
(4) Hypercortisolemia, even of low degree, “twists” our metabolism: cortisol blocks Deiodinase 1 in the peripheral cells, thereby preventing conversion of T4 to T3. It also “up regulates” deiodinase 3, which converts T4 to reverse T3 and converts any existing, or imported, T3 into T2, which is inactive.
(5) The net result is virtual elimination of T3 within the cells, so that there is an effective intracellular hypothyroidism, and reduction of serum free T3 to minimal levels, because serum FT3 is derived from T3 production by the peripheral cells.
(6) Hypothyroidism is a known cause of infertility and early abortion.
(7) Fetuses which survive the first eight weeks of gestation in the presence of maternal T3 deficiency are subject to imperfect brain development, between the 8th and 12th week of pregnancy.
(8) The immediate conclusion therefore, is: our female doctors, surgeons and trainees in particular, are liable to intracellular hypothyroidism due to their high-stress profession.

THE EFFECT of INTRACELLULAR HYPOTHYROIDISM in PREGNANCY

Hypothyroidism is a recognized cause of infertility, early spontaneous abortion and foetal maldevelopment. In particular, neural connection begins in the 8th week of pregnancy, but the fetus does not begin to make its own T3 until the 14th week. Furthermore, its thyroid gland does not achieve full function until the 20th week. Therefore the developing baby is entirely dependent on a supply of T3 from the mother. Therefore if the mother’s serum is depleted of T3, as occurs in intracellular hypothyroidism, the baby’s first 20 weeks in utero is spent in a state of deep hypothyroidism. This can lead to cognitive and physical deficits in the newborn.

The baby’s brain “connections” are started at about the 8th and the 8th week of pregnancy. If the mother is hypothyroid, or stressed enough to have intracellular hypothyroidism, while the “wiring” is being done, subtle abnormalities in brain growth may occur. Autism spectrum, schizophrenia, dyslexia, ADD, obesity and gender dysphoria are all related to maternal hypothyroidism, but no one has thought about intracellular hypothyroidism being a cause.

SOLUTION

Close surveillance during the first half of every pregnancy is prudent, because IH is due to hypercortisolemia and cortisol is released immediately in response to stress, so IH can develop at any time.

Protocol

(1) Test female doctors for intracellular hypothyroidism prior to deciding on a pregnancy, so that therapy for pre-existing IH can begin before conception.

(2) Repeat blood tests for IH upon diagnosis of pregnancy and at 4, 6 and 8 weeks of gestation, whether or not the initial tests diagnosed IH.

(3) Regardless of the timing of a positive test, initiate treatment with oral triiodothyronine as outlined in https://cbhrt.ca/intracellular-hypothyroidism/ , testing weekly to ensure appropriate dosage.

(5) For the fetus, continue the mother’s therapy until the 20th week of gestation, at which point it is able to make its own T4 and T3 (providing that the mother’s iodine and selenium levels are adequate).

(6) For the mother, it would be best to continue therapy with slow-release triiodothyronine throughout the pregnancy, with frequent estimations of serum FT3.

NOTES:

(1) Since DHEA levels fall progressively, 1% per annum beginning at age 26, and since DHEA production is sometimes deficient even before age 25, it would be wise to check DHEA also and to supplement it as seems necessary.

(2) Consideration should be given to testing all medical trainees and graduates for IH, on a regular basis: perhaps early diagnosis of intracellular hypothyroidism and ad hoc therapy would render “burnout” and other manifestations of IH diagnosable, treatable and manageable (regarding “burnout”, wouldn’t it be nice to diagnose, and treat it, instead of waiting for the stressed-out worker to “hit the wall”?

(3) I am retired and no longer licensed: as such, I cannot, and have no wish to, act as medical advisor to anyone, our female surgeons included.

(4) I am providing the above explanation and information in the interest of supplying our “lady doctors” with information which they may find useful and helpful, and not as instruction, directed at patients.

(5) This article should not be construed as constituting “advice” or “therapy” and the ideas herein should be discussed with a qualified “functional medicine” or “metabolic medicine” practitioner, whose advice should be considered carefully prior to instituting any of my suggestions.

(6) I would be happy to discuss this matter via email, if anyone has questions, via CBHRT.ca

G. A. Harry, Ex – MD, FRCSC (Urology), ABAARM (A4 M) – RETIRED.