What are the recommendations for diabetic women undergoing assisted reproductive techniques?

Recommendations for Diabetic Women Undergoing Assisted Reproductive Techniques

Diabetic women undergoing assisted reproductive techniques should achieve optimal glycemic control with A1C <6.5% before conception to minimize the risk of congenital anomalies and pregnancy complications. 1

Preconception Glycemic Management

• Target glycemic goals:

  • A1C <6.5% (ideally <6% if achievable without significant hypoglycemia) 1, 2
  • Fasting glucose <95 mg/dL (5.3 mmol/L) 1
  • 1-hour postprandial glucose <140 mg/dL (7.8 mmol/L) 1
  • 2-hour postprandial glucose <120 mg/dL (6.7 mmol/L) 1

• Medication management:

  • Discontinue potentially teratogenic medications before conception 2, 1:
    • ACE inhibitors and ARBs (category D in pregnancy)
    • Statins (category X)
    • Other oral antidiabetic agents with insufficient safety data
  • Insulin is the preferred treatment during pregnancy and fertility treatment 1
  • Consider referral to high-risk pregnancy clinic before fertility treatment (shown to significantly improve glycemic control) 3

Comprehensive Preconception Evaluation

• Required assessments before assisted reproductive techniques:

  • Baseline ophthalmologic examination (dilated eye exam) 2, 1
  • Renal function assessment (serum creatinine, urine albumin-to-creatinine ratio) 2, 1
  • Blood pressure evaluation and management 2
  • Cardiovascular disease screening according to ADA guidelines 2
  • Thyroid function tests (especially for type 1 diabetes due to 5-10% coincidence of thyroid disorders) 2, 1
  • Neurological assessment for autonomic and peripheral neuropathy 2

• Additional preconception screening:

  • Rubella immunity, syphilis, hepatitis B, HIV screening 1
  • Folic acid supplementation (minimum 400 mg daily) 1

Management During Assisted Reproductive Techniques

• Monitoring requirements:

  • Frequent glucose monitoring, including fasting and postprandial values 1
  • Regular A1C assessment (every 1-2 months) 2
  • Adjustment of insulin doses based on glucose patterns 2

• Technology considerations:

  • Continuous glucose monitoring (CGM) can be beneficial for women undergoing fertility treatment 4
  • Continuous subcutaneous insulin infusion (insulin pump therapy) may provide better glucose control with less hypoglycemia 4
  • Automated insulin delivery systems have shown benefits in pregnancy but require expert guidance 2

Management of Diabetic Complications

• Retinopathy:

  • Baseline eye exam before conception 2, 1
  • Follow-up exams every trimester as indicated by degree of retinopathy 2
  • Pregnancy may accelerate progression of retinopathy 1

• Nephropathy:

  • Women with protein excretion >190 mg/24h have increased risk for hypertensive disorders 2
  • Women with protein excretion >400 mg/24h are at risk for intrauterine growth restriction 2
  • Women with serum creatinine ≥3 mg/dl or creatinine clearance <50 ml/min should be counseled about 40% risk of permanent worsening of renal function during pregnancy 2

• Hypertension:

  • Aggressive monitoring and control of hypertension in the preconception period 2
  • Discontinue ACE inhibitors and ARBs before conception 2, 1

• Cardiovascular disease:

  • Screen for coronary artery disease (CAD) before conception 2
  • Untreated CAD is associated with high mortality during pregnancy 2
  • Exercise tolerance should be normal before conception 2

Common Pitfalls and Considerations

• Pitfalls to avoid:

  • Relying solely on A1C instead of also monitoring pre- and postprandial glucose values 1
  • Failing to discontinue potentially teratogenic medications before conception 2, 1
  • Inadequate frequency of insulin dose adjustments during fertility treatment and early pregnancy 1
  • Proceeding with fertility treatment despite poor glycemic control 3, 5

• Important considerations:

  • Women with preexisting diabetes have higher rates of adverse pregnancy outcomes than those with gestational diabetes 6, 5
  • Type 1 diabetes patients typically have worse glycemic control and higher rates of preeclampsia and stillbirth 6
  • Women with poor glycemic control (HbA1c >6.5%) have significantly higher rates of preterm labor, miscarriages, operative deliveries, and neonatal complications 5

By implementing these recommendations, healthcare providers can optimize outcomes for diabetic women undergoing assisted reproductive techniques, minimizing the risk of maternal and fetal complications.