What are the guidelines for assisted reproductive techniques (ART) in diabetic women?

Guidelines for Assisted Reproductive Techniques in Diabetic Women

Diabetic women undergoing assisted reproductive techniques (ART) must achieve optimal glycemic control with A1C <6.5% before conception to minimize risks of congenital anomalies, pregnancy complications, and adverse outcomes. 1, 2

Preconception Care Requirements

Glycemic Control Targets

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

Essential Preconception Assessments

1. Comprehensive diabetes evaluation:

   • Evaluation of diabetes complications (retinopathy, nephropathy, neuropathy)
   • Assessment for DKA risk and severe hypoglycemia history 1

2. Comorbidity screening:

   • Hypertension evaluation and management
   • Lipid panel
   • Thyroid function tests (especially for type 1 diabetes)
   • PCOS assessment (if applicable) 1, 2

3. Ophthalmologic examination:

   • Comprehensive dilated eye exam to assess retinopathy status
   • Women with preexisting retinopathy need close monitoring during pregnancy 1, 2

4. Renal function assessment:

   • Serum creatinine
   • Urine albumin-to-creatinine ratio
   • Women with protein excretion >190 mg/24h have increased risk for hypertensive disorders 1, 2

5. Cardiovascular screening:

   • ECG in women starting at age 35 with cardiac symptoms or risk factors
   • Further cardiac evaluation if abnormal findings 1

Medication Management

Required Medication Changes

• Discontinue potentially teratogenic medications:

  • ACE inhibitors and ARBs (pregnancy category D)
  • Statins (pregnancy category X)
  • Some glucose-lowering agents not approved in pregnancy 1, 2

• Preferred treatment:

  • Insulin is the preferred treatment during pregnancy and fertility treatment
  • Medication changes should occur with sufficient time to stabilize conditions before conception 1, 2

Supplementation

• Folic acid supplement (400-800 mg/day) 1

Monitoring Requirements During ART

1. Glucose monitoring:

   • Regular blood glucose monitoring (fasting, preprandial, and postprandial)
   • Consider continuous glucose monitoring if indicated 1

2. A1C assessment:

   • Every 1-2 months to monitor glycemic control 2

3. Regular follow-up:

   • More frequent visits to adjust insulin doses based on glucose patterns
   • Insulin requirements may change significantly during early pregnancy 2

Common Pitfalls to Avoid

1. Inadequate preconception planning:

   • Studies show that 61% of diabetic women present for prenatal care with suboptimal glycemic control (A1C >8%) 3
   • Women not advised about target glucose levels are more likely to enter pregnancy with poor control 3

2. Relying solely on A1C:

   • Using only A1C instead of also monitoring pre- and postprandial glucose values 2
   • Not adjusting insulin doses frequently enough to match changing requirements 2

3. Inadequate contraception:

   • Unplanned pregnancies with poor glycemic control lead to higher rates of congenital malformations
   • Effective contraception must be used until glycemic targets are achieved 1, 2

Impact of Glycemic Control on Outcomes

• HbA1C levels correlate directly with the occurrence of congenital malformations and other neonatal complications 4
• Risk of diabetic embryopathy (anencephaly, microcephaly, congenital heart disease, renal anomalies) is directly proportional to A1C elevations during the first 10 weeks of pregnancy 1
• Women with type 1 diabetes typically show worse glycemic control than those with type 2, both preconception and during pregnancy 5
• Referral to high-risk pregnancy clinics before fertility treatment significantly improves glycemic control (median A1C 6.1% vs 7.1% with usual care) 6

By following these guidelines, diabetic women can minimize risks and optimize outcomes when undergoing assisted reproductive techniques.