An interview with Dr. Grace Charles

Every month has the same shape. The waiting, a symptom that could be early pregnancy or could just be PMS, then your period, then starting over again. Every test so far has come back normal, and normal is not the same as nothing being wrong.

Two of those three pathways never show up on a TSH. Your doctor might not have mentioned the risk of Hashimoto’s and fertility challenges.

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Hashimoto’s often starts during one of the three Ps

I have said on the podcast before that women tend to develop Hashimoto’s during one of the three Ps. Puberty, pregnancy, and perimenopause.

Dr. Grace Charles is a naturopathic fertility doctor. Her work is helping women and couples find out why they have not gotten pregnant naturally, before they spend money on IVF. Many of her patients arrive carrying a diagnosis of unexplained infertility.

For a lot of those women, she said, the answer turns out to be Hashimoto’s.

She sees the second P constantly. It shows up as secondary infertility. Baby number one came without any trouble, and three or four years later nobody can explain why baby number two has not.

“It’s often because of that second P during pregnancy, these hormonal shifts that change the thyroid cascade, change the way the immune system is working, and can trigger Hashimoto’s,” she said.

The place she catches it most is the postpartum period, especially when a woman is having a hard time after a birth. That is when she starts pushing for antibody testing.

How a high TSH can stop ovulation

This is the pathway conventional medicine usually catches.

When TSH is elevated, TRH (thyroid releasing hormone) picks up that thyroid function is low, and TRH goes up. When TRH goes up, prolactin goes up. Prolactin suppresses FSH and LH.

FSH and LH are the hormones that ripen the egg and release it. Dr. Grace described them as the brain telling the ovaries to ovulate.

When they are suppressed, one of two things happens.

“So we see poor ovulation because the egg hasn’t ripened sufficiently and we’re sending out kind of an underripe egg. Or the ovulation doesn’t happen at all. So we see anovulatory cycles,” she said.

This one gets found because it is the test that gets run. A woman tells her gynecologist she has been trying for a year. The gynecologist runs a TSH.

If that TSH comes back above 2.5, she gets thyroid hormone. Sometimes that really is all it takes, because that was the pathway causing the problem.

Sometimes it is not.

The thyroid receptors nobody tests for

There are receptors inside the follicle itself. TSH receptors, and thyroid receptors.

The thyroid receptors there are for a thyroid hormone called T2. We do not talk about T2 much, because there is no test for it. T3 turns into T2, so if free T3 is robust, the working assumption is that there is enough T2.

Conventionally, free T3 does not get run.

So if your TSH looks good and your T4 looks good, low thyroid hormone inside the follicle never gets caught. And it matters there, because thyroid hormone helps the egg develop. Without enough of it reaching the follicle, ovulation quality drops.

Your labs can look normal while something real is happening.

What antibodies do to the wall of the uterus

This third pathway is specific to Hashimoto’s.

The endometrium is the wall of the uterus. It is covered in TSH receptors. Dr. Grace’s word for how many was “tons.”

Hashimoto’s is the immune system attacking thyroid hormone, thyroid hormone receptors, and TSH receptors. That attack is not confined to your neck. It is also happening in the exact tissue where a pregnancy has to attach.

“So we’ll see in women with Hashimoto’s, because of the inflammation and the autoimmune activity in the wall of the uterus, that we’re seeing miscarriages or just infertility in general,” she said.

Thyroid hormone is one problem. The immune system attacking is a separate problem. Thyroid medication answers the first one and does nothing about the second.

I am a nurse and I had read about thyroid problems and miscarriage before. Nobody had ever explained it to me that way.

Why Hashimoto’s and fertility problems often show up after a baby

Dr. Grace has one red flag symptom she watches for above all the others.

“What I see the most is scary thoughts postpartum,” she said. She was careful to name that as something she sees in her clinic. “I don’t have a ton of studies to back this up.”

Postpartum depression and postpartum anxiety are blanket terms that cover a lot of ground. What she listens for underneath them is specific.

Worrying about the baby constantly. Worrying that the crib will break in the middle of the night. Wondering what would happen if you drove off the road.

She also listens for lying awake when the baby is finally sleeping, feeling grumpy, mental fog, and being tired in a way that lack of sleep does not explain.

If thoughts like that are happening for you, tell your provider about the thoughts themselves. That is its own conversation, and it deserves real support. Ask for the antibodies in the same appointment.

When she described that pattern, I thought about my third baby.

I had never had any trouble driving. After he was born, every time a semi passed me on the road I had an irrational fear, along with all the physical symptoms of anxiety. It came out of nowhere and it was not like me.

After that third baby, I had my first miscarriage. I was not diagnosed with Hashimoto’s at the time.

I have recorded almost 200 episodes about this condition and I have never been able to pinpoint when I got it. Listening to her, I wondered if that was it. That was my second P.

Her advice for anyone in that position is blunt. “Go to your doctor, make them test your thyroid antibodies. Don’t take no for an answer.”

The thyroid panel to ask for

Step one is the same for everyone, whether the problem is not getting pregnant or not staying pregnant. Get the full thyroid panel run.

That means TSH, free T4, free T3, and all of the antibodies. Each one covers a different pathway.

TSH covers the first. Free T4 and free T3 cover egg development. The antibodies cover what is happening in the uterus.

Here are the numbers Dr. Grace works toward with her own fertility patients:

“Get the TSH below a 2.5. I like it a little bit below a 2 for my fertility patients. We keep it really tight. We want to get the T4 above a 1. We want to get the T3 well above a 3.”

Those are her targets, inside her practice, for women actively trying to conceive. They are not a universal standard and they are not a number I am setting for you. They are worth knowing before you walk into an appointment.

She described two parts to thyroid care in Hashimoto’s. First, get the numbers right with what is available. Second, do the work of bringing the antibodies down.

Knowing your antibody number matters even when you already have the diagnosis. It gives you a starting point to measure against, which is exactly why ignoring antibodies is such a problem.

Unexplained infertility is not a diagnosis

Dr. Grace is direct about this one.

“That’s not really a diagnosis. That’s a, we haven’t figured out your diagnosis yet,” she said.

Her position is that we diagnose first and treat second, because that is good medicine. Being sent straight to IVF without a diagnosis means going into a very big treatment without knowing what is being treated.

Sometimes the answer is Hashimoto’s. Sometimes it is endometriosis. Sometimes it is subfertility in the male partner, which she said is hard to treat because it is hard to get men on board, but easy to diagnose with a semen analysis and good blood work.

Even when a patient walks in already knowing she has Hashimoto’s, Dr. Grace goes further. Why do you have Hashimoto’s? Something is telling the immune system to attack your own body, and that something has to be found.

The examples she gave were ordinary. A significant imbalance in the gut microbiota. Or three minutes of deep sleep a night, which means missing the window between 10 p.m. and 2 a.m. when antioxidants are most active.

Once the issue is pinpointed, she treats step by step until the fertility markers improve. And if pregnancy still does not happen naturally, her patients go into IVF in a much stronger position.

How long this actually takes

We want microwave results. I said that to her, and she laughed, because she hears it constantly.

Six months of care is her realistic average. Sometimes eight, when the antibodies are stubborn. That timeline assumes a patient who is on board with the plan, willing to make some dietary changes, and willing to make room for better boundaries and self care.

She works almost exclusively with type A women. Good at their jobs, good at turning what they want into reality, not used to not getting it. For them, she said, the timeline is the hardest pill to swallow.

The part that surprised me is that she asks patients not to try during those months.

Part of that is the loop. “Every time they get a period, they’re reminded. Every time they have a symptom of PMS, it could look a lot like an early pregnancy symptom, they’re reminded.” Stepping off that roller coaster protects her patients’ mental health while the work is happening.

The other part is the outcome she is after. She wants the pregnancy to be a healthy baby, not a loss.

“For Hashimoto’s, I try not to give patients the green light to start trying again until we’ve really gotten to the root cause and healed a lot of these systems,” she said.

Her closing thought was this. “We can treat it. And if you are someone with Hashimoto’s who’s struggling to get or stay pregnant, there’s hope for you.”

You can find Dr. Grace at drgracecharles.com, where you can book a free call with her. Her free list of 10 things you can do today to improve your fertility is worth grabbing.

Where this leaves you

You know now that there are three pathways, and that the one test most women get only looks at one of them. That is enough to change what you ask for at your next appointment.

The one thing to do is ask for the full panel. TSH, free T4, free T3, and the antibodies. If the answer is no, ask again.

If it helps to walk in with the questions already written down, 10 Thyroid Questions to Ask Your Doctor is free. Grab it and bring it to your next appointment.