Management of Diabetes Mellitus in Patients Undergoing In Vitro Fertilization
Early screening for gestational diabetes mellitus (GDM) is strongly recommended for all patients with diabetes mellitus undergoing IVF, with screening ideally performed before 20 weeks of gestation due to significantly higher risk of GDM in IVF pregnancies.
Pre-IVF Assessment and Optimization
Glycemic Control
- Target HbA1c <7.0% before starting IVF to decrease microvascular complications and improve pregnancy outcomes 1
- For patients with pre-existing diabetes, strict preconception glycemic control is essential before participating in IVF programs 2
- Patients should work with their clinicians to achieve target HbA1c of <7.5% before proceeding with IVF 1
Cardiovascular Assessment
- Perform thorough cardiovascular evaluation in patients with diabetes before IVF
- Yearly screening for peripheral arterial disease with clinical assessment and/or ankle-brachial index measurement 1
- Consider consultation with endocrinologist for patients with poorly controlled diabetes 1
During IVF Treatment
Glucose Monitoring
- Implement intensive blood glucose monitoring during ovarian stimulation
- Target glucose values:
- Fasting plasma glucose (FPG) <5.3 mmol/L (<95 mg/dL)
- 1-hour postprandial <7.8 mmol/L (<140 mg/dL) or
- 2-hour postprandial <6.7 mmol/L (<120 mg/dL) 1
Insulin Management
- For patients requiring insulin:
Medication Considerations
- For patients with type 2 diabetes and cardiovascular disease, consider:
- SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) to reduce cardiovascular events
- GLP-1 RAs (liraglutide, semaglutide, or dulaglutide) 3
- Adjust medications as needed during ovarian stimulation
Post-IVF and Pregnancy Management
Early GDM Screening
Glucose Monitoring During Pregnancy
- Implement self-blood glucose monitoring (SMBG) from the first antenatal visit 5
- For GDM diagnosis, perform 75-g oral glucose tolerance test (OGTT) 1
- Monitor HbA1c monthly during pregnancy (target <6% if achievable without significant hypoglycemia) 1
Management of GDM in IVF Pregnancies
- First trimester fasting glucose levels are significantly higher in IVF pregnancies compared to spontaneous pregnancies 6
- Complications in GDM IVF pregnancies are associated with 1-hour postprandial blood glucose levels 5
- IVF pregnancies with GDM have higher rates of preeclampsia and cesarean sections 5
Postpartum Follow-up
Postpartum Testing
- Test for prediabetes or diabetes 4-12 weeks postpartum using non-pregnant OGTT criteria 1
- Implement lifelong screening for diabetes in women with a history of GDM at least every 3 years 1
Special Considerations
Potential Complications
- IVF pregnancies affected by GDM are prone to increased maternal and fetal complications 5
- Week of delivery is typically earlier for GDM IVF pregnancies (37 ± 1.7 weeks) compared to non-GDM IVF pregnancies (37.9 ± 0.9 weeks) 5
- Higher rates of preeclampsia and cesarean sections (84.8%) in GDM IVF pregnancies 5
Patient Education
- Provide structured education on diabetes management, including glucose monitoring and medication adherence 3
- Discuss the importance of maintaining near-normal glucose levels and blood pressure 1
- Emphasize the need for timely intervention despite good vision and no ocular symptoms 1
By following these guidelines, healthcare providers can optimize outcomes for patients with diabetes mellitus undergoing IVF, with particular attention to early screening and management of GDM, which occurs at significantly higher rates in IVF pregnancies.