What are the recommendations for individuals with diabetes undergoing In Vitro Fertilization (IVF)?

Management of Diabetes in Patients Undergoing IVF

Women with diabetes who are planning to undergo IVF should achieve optimal glycemic control (A1C <6.5%) before conception to minimize risks of congenital anomalies, preeclampsia, macrosomia, and preterm birth. 1

Preconception Care for Diabetic Patients Considering IVF

• Preconception counseling is essential for all women with diabetes planning pregnancy, including those pursuing IVF, to reduce risks of congenital malformations and adverse pregnancy outcomes 1
• Target A1C should be <6.5% (48 mmol/mol) before conception to minimize risks to the developing fetus 1
• Women with diabetes should ideally receive care from a multidisciplinary team including an endocrinologist, maternal-fetal medicine specialist, registered dietitian, and diabetes educator before beginning IVF 1
• Screening and treatment for diabetes complications (retinopathy, nephropathy, neuropathy, cardiovascular disease) should be completed before conception 1
• Potentially harmful medications must be discontinued before conception:
  • ACE inhibitors and ARBs (category D in later pregnancy) 1
  • Statins (pregnancy category X) 1
  • Oral antidiabetic agents should generally be discontinued during pregnancy, though metformin and acarbose are category B 1

Special Considerations for IVF in Diabetic Patients

• IVF appears to be an independent risk factor for gestational diabetes mellitus (GDM), particularly in overweight women (BMI >25 kg/m²) 2
• First trimester fasting glucose levels may be significantly higher in IVF pregnancies compared to spontaneous conceptions 3
• Early GDM screening is warranted in IVF pregnancies, as 37.6% of GDM diagnoses in IVF pregnancies occur before the 24th week of gestation 4
• IVF pregnancies complicated by GDM may have higher rates of preeclampsia and cesarean section 4
• Tight glycemic control is essential during IVF procedures, as complications in GDM-IVF pregnancies are associated with 1-hour postprandial blood glucose levels 4

Insulin Management During IVF Procedures

• For patients using insulin pumps (CSII) who require procedures during IVF treatment:

  • For minor procedures where the patient will resume eating shortly afterward, insulin pump therapy can typically be continued 1
  • For major procedures or those requiring NPO status for extended periods, transition to intravenous insulin may be necessary 1
  • When transitioning from pump to IV insulin, start IV insulin at least 30 minutes before removing the pump to prevent rapid hyperglycemia and ketosis 1
  • The basal rate programmed in the pump provides guidance for IV insulin requirements 1

• For patients on multiple daily injections:

  • Rapid-acting insulin analogs are preferred to reduce hypoglycemia risk 1
  • Education on matching prandial insulin to carbohydrate intake, pre-meal glucose levels, and anticipated activity is important 1

Post-IVF Pregnancy Management

• Insulin resistance decreases dramatically immediately postpartum, and insulin requirements often decrease to roughly half of prepregnancy requirements 1
• Patients with type 1 diabetes using insulin pumps should have continued access to this therapy throughout pregnancy and beyond 1
• Regular monitoring of blood glucose is essential, with targets individualized based on hypoglycemia risk 1
• Dilated eye examinations should be performed before pregnancy or in the first trimester, then monitored every trimester and for 1 year postpartum 1
• For patients with chronic hypertension, blood pressure targets of 110-135/85 mmHg are recommended during pregnancy 1

Contraception and Future Planning

• A contraceptive plan should be discussed and implemented with all diabetic women of reproductive potential 1
• Long-acting, reversible contraception may be ideal for individuals with diabetes 1
• Women with a history of GDM should have lifelong screening for type 2 diabetes every 1-3 years 1
• Lifestyle interventions and/or metformin should be considered for women with history of GDM and prediabetes to prevent progression to diabetes 1

Pitfalls and Caveats

• IVF may predispose individuals to increased incidence of obesity, elevated blood pressure, fasting glucose, and triglycerides later in life 5
• Overweight or obese women contemplating IVF should be advised to lose weight before the procedure to reduce GDM risk 2
• Patients with insulin pumps must remove them during radiological procedures (CT, MRI) due to potential device failure from electromagnetic fields 1
• The risk of hypoglycemia may increase during breastfeeding, requiring adjustment of insulin doses 1
• Postpartum care should include psychosocial assessment and support for self-care 1

By following these guidelines, patients with diabetes undergoing IVF can minimize risks and optimize outcomes for both mother and child.