Management of Diabetes Medications During IVF Egg Retrieval
Discontinue glimepiride and sitagliptin on the day of egg retrieval; metformin may be continued through the procedure but should be stopped once pregnancy is confirmed.
Medication-Specific Recommendations
Metformin
- Metformin can be safely continued through egg retrieval in women with PCOS or type 2 diabetes undergoing IVF, as it may reduce the risk of ovarian hyperstimulation syndrome (OHSS) and improve pregnancy outcomes 1, 2
- Metformin reduces OHSS incidence from 20% to 6-14% when used during ovarian stimulation 2
- However, metformin must be discontinued immediately once pregnancy is confirmed, as there is no evidence-based need to continue it beyond conception in PCOS patients 3, 4, 5
- For women with pre-existing type 2 diabetes, transition to insulin therapy should ideally occur before IVF begins, as insulin is the preferred agent for diabetes management during pregnancy 3, 6
Glimepiride (Sulfonylurea)
- Glimepiride should be held on the day of egg retrieval due to the risk of hypoglycemia during the fasting period required for the procedure 3
- Sulfonylureas are associated with higher rates of neonatal hypoglycemia (compared to insulin or metformin) and cross the placenta at approximately 70% of maternal levels 3
- If pregnancy occurs, glimepiride must be discontinued and replaced with insulin, as sulfonylureas are not recommended during pregnancy 3, 6
Sitagliptin (DPP-4 Inhibitor)
- Sitagliptin should be held on the day of egg retrieval due to lack of safety data in pregnancy and the procedural fasting requirement 7, 8
- There is no published evidence supporting the safety of DPP-4 inhibitors during pregnancy or IVF procedures
- Sitagliptin must be discontinued if pregnancy is achieved, as it is not an approved medication for use during pregnancy
Procedural Algorithm for Egg Retrieval Day
Pre-Procedure (Morning of Retrieval)
- Hold glimepiride to prevent hypoglycemia during NPO period 3
- Hold sitagliptin due to lack of pregnancy safety data 7, 8
- Metformin may be continued at the usual morning dose if taken, though some practitioners prefer to hold it due to the NPO requirement 1, 2
Post-Procedure Management
- Resume metformin immediately after the procedure if pregnancy has not yet been confirmed 1
- Do not resume glimepiride or sitagliptin—transition to insulin if glycemic control requires additional medication beyond metformin 3, 6
- Monitor blood glucose closely in the immediate post-retrieval period, especially if sulfonylurea was held 3
Critical Transition Points
If Pregnancy Is Confirmed
- Discontinue metformin immediately once pregnancy is documented, as there is no evidence-based benefit for continuing it in PCOS patients and concerning long-term metabolic effects have been observed in exposed offspring 3, 4, 5
- Transition to insulin therapy for all glycemic control needs during pregnancy, as insulin is the only guideline-recommended agent for diabetes management in pregnancy 3, 6
- Achieve target glucose levels: fasting <95 mg/dL, 1-hour postprandial <140 mg/dL, or 2-hour postprandial <120 mg/dL 5, 6
If Pregnancy Does Not Occur
- Resume pre-IVF diabetes regimen including glimepiride and sitagliptin if these were part of the patient's baseline therapy 7, 8
- Continue metformin through subsequent IVF cycles if PCOS is present, as it may improve outcomes 1, 2
Common Pitfalls to Avoid
- Do not continue sulfonylureas into pregnancy—the 70% placental transfer and increased neonatal hypoglycemia risk make this unsafe 3
- Do not assume metformin should be continued throughout pregnancy in PCOS patients—randomized trials show no benefit in preventing gestational diabetes or miscarriage once pregnancy is established 3, 4
- Do not restart glimepiride or sitagliptin after egg retrieval if there is any possibility of pregnancy—transition to insulin instead 3, 6
- Monitor for hypoglycemia closely when holding sulfonylureas, especially in patients with poor baseline glycemic control 3