OBJECTIVES: The use of levothyroxine (LT4) treatment aiming to improve fertility in euthyroid women with positive thyroid peroxidase antibodies (TPOAb) is not supported by the available evidence. The aim of the study was to document the use of LT4 by European thyroid specialists in such patients. DESIGN: The data presented derive from Treatment of Hypothyroidism in Europe by Specialists, an International Survey (THESIS), a questionnaire conducted between 2019 and 2021 to document the management of hypothyroidism by European thyroid specialists. Here, we report the aggregate results on the use of LT4 in infertile, euthyroid women with positive TPOAb. RESULTS: A total of 2316/5406 (42.8%) respondents stated that LT4 may be indicated in TPOAb positive euthyroid women with infertility. The proportion of those replying positively to this question varied widely across different countries (median 39.4, range 22.9%-83.7%). In multivariate analyses males (OR: 0.8; CI: 0.7-0.9) and respondents >60 years (OR: 0.7; 0.6-0.8) were the least inclined to consider LT4 for this indication. Conversely, respondents managing many thyroid patients ("weekly" [OR: 1.4; CI: 1.0-1.9], "daily" [OR: 1.8; CI: 1.3-2.4]) and practicing in Eastern Europe (OR: 1.5; CI: 1.3-1.9) were most likely to consider LT4. CONCLUSIONS: A remarkably high number of respondents surveyed between 2019 and 2021, would consider LT4 treatment in TPOAb positive euthyroid women with infertility. This view varied widely across countries and correlated with sex, age and workload, potentially influencing patient management. These results raise concerns about potential risks of overtreatment.

3rd Department of Medicine 1st Faculty of Medicine General University Hospital Charles University Prague Czech Republic

5th Department of Internal Medicine Medical Faculty of Comenius University and University Hospital Bratislava Slovakia

5th Medical Department Division of Endocrinology and Diabetes Medical Faculty Mannheim Heidelberg University Mannheim Germany

Cabinet Médical 2 rue Bellefontaine Lausanne Switzerland

Clinic of Endocrinology and Metabolism Medical Faculty University Hospital Sofiamed Sofia University Saint Kliment Ohridski Sofia Bulgaria

Department of Clinical Therapeutics School of Medicine Endocrine Unit and Diabetes Centre Alexandra Hospital National and Kapodistrian University of Athens Athens Greece

Department of Endocrinology and Metabolism Amsterdam UMC University of Amsterdam Amsterdam The Netherlands

Department of Endocrinology and Metabolism Koru Ankara Hospital Ankara Turkey

Department of Endocrinology and Metabolism Regina Apostolorum Hospital Albano Laziale Rome Italy

Department of Endocrinology and Nutrition Université Catholique de Louvain Brussels Belgium

Department of Endocrinology Belarusian State Medical University Minsk Republic of Belarus

Department of Endocrinology Carol Davila University of Medicine and Pharmacy Bucharest Romania

Department of Endocrinology Clínica Universidad de Navarra Pamplona Spain Instituto de Investigación Sanitaria de Navarra Pamplona Spain

Department of Endocrinology Diabetes and Metabolic Diseases Mladen Sekso University Hospital Center Sisters of Mercy Zagreb Croatia

Department of Endocrinology Diabetes and Metabolism Medical Faculty University of Coimbra Coimbra Portugal

Department of Endocrinology Diabetes and Metabolism University Hospital Essen University Duisburg Essen Essen Germany

Department of Endocrinology Diabetes Centre Hellenic Red Cross Hospital Athens Greece

Department of Endocrinology Hospital Universitario Puerta de Hierro Majadahonda Madrid Spain

Department of Endocrinology Metabolism and Internal Medicine Poznan University of Medical Sciences Poznań Poland

Department of Endocrinology No 1 N 5 Sklifosovsky Institute of Clinical Medicine 1 M Sechenov 1st Moscow State Medical University Moscow Russian Federation

Department of Endocrinology Odense University Hospital Odense Denmark

Department of Endocrinology Skåne University Hospital Malmö Sweden

Department of Endocrinology Tampere University Hospital Tampere Finland

Department of Internal Medicine and Endocrinology Medical University of Warsaw Warsaw Poland

Department of Internal Medicine Clinic of Endocrinology and Metabolism University Hospital Alexandrovska Medical University Sofia Sofia Bulgaria

Department of Internal Medicine Division of Endocrinology Faculty of Medicine Gaziantep University Gaziantep Turkey

Department of Internal Medicine Endocrine Unit Brussel Belgium

Department of Internal Medicine Rotterdam Thyroid Center Erasmus Medical Center Rotterdam The Netherlands

Department of Medicine 1 Klinikum Vest GmbH Knappschaftskrankenhaus Recklinghausen Academic Teaching Hospital Ruhr University Bochum Mannheim Germany

Department of Medicine Division of Endocrinology Faculty of Medicine University of Debrecen Debrecen Hungary

Department of Medicine Universidad Autónoma de Madrid Madrid Spain

Department of Reproductive Endocrinology Institute of Endocrinology and Metabolism 5 P Komissarenko National Academy of Medical Science of Ukraine Kyiv Ukraine

Department of Surgery Tampere University Hospital Tampere Finland

Diabetes and Endocrinology Section Beacon Hospital Dublin Ireland

Division of Endocrinology Diabetes and Metabolism University of Lausanne Lausanne Switzerland

Division of Endocrinology Presidio Ospedaliero 5 Fazzi Lecce Italy

East Surrey Hospital Surrey and Sussex Healthcare NHS Trust Redhill Surrey UK

Endocrine Department St Vincent's University Hospital Dublin Ireland

Endocrinology and Metabolism Institute and Davidoff Center Rabin Medical Center Faculty of Medicine Tel Aviv University Petah Tikva Israel

Endocrinology Diabetes and Metabolism Service Centro Hospitalar Universitário de Santo António Porto Portugal

Faculty of Medicine University of Belgrade Belgrade Serbia

Institute of Endocrinology and Metabolism 5 P Komisarenko National Academy of Medical Sciences of Ukraine Kyiv Ukraine

Institute of Translational and Clinical Research Newcastle University Newcastle upon Tyne UK

Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana Majadahonda Spain

Internal Medicine 3 Division of Endocrinology and Metabolism Medical University of Vienna Vienna Austria

Rabin Medical Center Hasharon Campus Petach Tikva Israel

Robert Graves Institute Tallaght University Hospital Dublin Ireland

School of Medicine University College Dublin Dublin Ireland

Scientific Committee Associazione Medici Endocrinologi Milan Italy

Section of Clinical Medicine Faculty of Health and Medical Sciences University of Surrey Guildford Surrey UK

Thyroid and Osteoporosis Praxis Kumberg Austria Thyroid Practice for Radiofrequency Ablation Vienna Austria

Thyroid Diseases and Endocrine Tumor Department GRC 16 Thyroid Tumors APHP Hôpital Pitié Salpêtriére Sorbonne University Paris France

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