How does diabetes affect fertility and what management strategies can improve conception?

Diabetes and Fertility: Impact and Management Strategies

Diabetes significantly affects fertility and requires preconception glycemic control with an A1C <6.5% to improve conception rates and reduce pregnancy complications. 1

Impact of Diabetes on Fertility

Diabetes affects fertility and pregnancy outcomes in several important ways:

• Increased risk of pregnancy complications: Uncontrolled diabetes is associated with higher rates of:

  • Spontaneous abortions/miscarriages 1, 2
  • Congenital malformations 1, 3
  • Preeclampsia 1
  • Preterm delivery 1, 2
  • Macrosomia 2
  • Stillbirth 1

• Embryonic development risks: Poor glycemic control during the first 10 weeks of pregnancy (when organogenesis occurs) directly increases the risk of congenital anomalies including anencephaly, microcephaly, congenital heart disease, and renal anomalies 1

• Maternal health complications: Poorly controlled diabetes increases maternal risks for diabetic ketoacidosis, preeclampsia, and delivery complications 4

Management Strategies to Improve Conception

1. Preconception Care

• Multidisciplinary approach: Individuals with diabetes planning pregnancy should ideally receive care from a team including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care educator 1

• Glycemic targets:

  • Achieve A1C <6.5% before conception 1
  • Implement daily blood glucose monitoring with targets of fasting glucose <95 mg/dL and 1-hour postprandial glucose <140 mg/dL or 2-hour postprandial glucose <120 mg/dL 1

• Medication review and adjustment:

  • Discontinue potentially harmful medications including ACE inhibitors, angiotensin receptor blockers, and statins 1, 5
  • For patients on metformin: Limited data show no clear association with major birth defects, but risks of poorly controlled diabetes are significant 4
  • For insulin users: May need dose adjustments before and during pregnancy 6

2. Comprehensive Health Assessment

• Diabetes-specific testing 1:

  • A1C measurement
  • Creatinine and urinary albumin-to-creatinine ratio
  • Comprehensive eye examination (ideally before pregnancy or in first trimester)
  • Screening for other diabetes complications

• General health evaluation 5:

  • Thyroid function tests
  • Blood pressure assessment
  • Complete blood count
  • Blood type and Rh status

3. Lifestyle Modifications

• Nutrition counseling 1:

  • Comprehensive nutrition assessment
  • Meal planning
  • Correction of dietary deficiencies
  • Weight management if overweight/obese

• Physical activity 1:

  • Regular moderate exercise
  • Adequate sleep
  • Avoidance of hyperthermia (hot tubs)

• Supplementation 1, 5:

  • Folic acid (400 mg routinely, or 4-5 mg if diabetic)
  • Appropriate use of over-the-counter medications

4. Diabetes Self-Management Education

• Comprehensive education on 1:
  • Blood glucose monitoring techniques
  • Insulin adjustment (if applicable)
  • Hypoglycemia prevention and management
  • Hyperglycemia prevention
  • Sick day management

Evidence of Effectiveness

Research demonstrates significant benefits of preconception care for diabetic women:

• Women attending preconception programs have significantly better glycemic control in early pregnancy 7, 8

• Preconception care reduces spontaneous abortion rates from 24% to 7% 7

• Major congenital anomalies decrease from 10.9% to 1.2% with preconception diabetes management 3

• Women receiving specialized care in high-risk pregnancy clinics before fertility treatment have better glycemic control (median HbA1C 6.1% vs 7.1%) 8

Common Pitfalls and Caveats

• Unplanned pregnancies: Many women with diabetes do not plan their pregnancies, leading to suboptimal glycemic control during critical early development 9

• Knowledge gaps: Many women may not be aware of the specific risks diabetes poses to pregnancy 9

• Medication concerns: Some diabetes medications require adjustment or discontinuation before conception 1, 4

• Hypoglycemia risk: Intensive glycemic control increases risk of hypoglycemia, which requires careful monitoring and management 3

• Retinopathy progression: Pregnancy can worsen diabetic retinopathy, necessitating regular eye examinations 1

• Access barriers: Some patients face challenges accessing specialized care or adhering to intensive management protocols 9

By implementing these management strategies with a focus on preconception glycemic control, individuals with diabetes can significantly improve their chances of conception and reduce the risk of adverse pregnancy outcomes.