Evaluating Care For Women With Diabetes Undergoing Fertility Treatments

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A study conducted in Haifa, Israel and published in Diabetes Care, determined that medical care for women with diabetes who undergo fertility treatments is suboptimal.  The study, believed to be the first of its kind, found that although women with diabetes undergoing fertility treatments received more care overall than women with spontaneous pregnancies, prior to conception, less than one-quarter of these patients prepared themselves for pregnancy by taking folic acid regularly (a standard in preconception care).  Moreover, only one-third achieved good glycemic control prior to fertility treatment.

I had the opportunity to discuss this study and its surprising results with its lead author Dr. Shlomit Riskin-Mashiah, M.D.

Why did you decide to investigate the care of diabetic women undergoing fertility treatments? 

I’m an obstetrician with a maternal fetal medicine sub-specialty. I work in high risk pregnancy clinics of Clalit Health Services in Israel. Too often I see pregnant women after fertility treatment referred for follow up because of underlying medical problems (such as diabetes) that were not treated adequately before the fertility treatment. This study evaluated, retrospectively, the quality of medical care in diabetic women during their fertility treatments.

Are women with diabetes a particularly “at-risk” group?

A woman with diabetes is considered a high risk pregnancy because of the potential ill effects the disease might pose on the women and fetus during pregnancy.

Women undergoing fertility treatments are – on average – older and have more chronic medical problems. Also the risk for multiple pregnancies is much higher after fertility treatment. All these factors render more women with fertility problems into a high risk pregnancy.

Can fertility treatments affect blood sugar levels?

Not as far as I know, however many infertile women are obese and have PCOS (polycystic ovary syndrome), which often goes with insulin resistance.

What does it mean that care is suboptimal?

As explained in the article, there are many guidelines for preconception care in diabetic patients. These guidelines recommend regular preconception use of folic acid; good diabetic control with HbA1c less than 6-7.0% and discontinuation before conception of teratogenic drugs. We found in the study that many women undergo fertility treatment despite poor glycemic control (only 31% had a HbA1c <7.0%), only one quarter used folic acid regularly and too many continued the use of potentially harmful medications in the first trimester of pregnancy. Moreover, diabetic women who used assisted reproduction techniques were not prepared better for pregnancy compared to diabetic women with spontaneous pregnancies.

 Does the level of care affect chances of becoming pregnant?

We did not check this in this work. However it is known that women with uncontrolled diabetes have much higher risk for spontaneous abortion and fetal malformation.

Given that the study looked at a specific patient group and the level of care received, how transferable is the conclusion to other hospitals and other countries?

As far as I know, this is the first study to look at the quality of medical care in diabetic women undergoing fertility treatments. However, as we point in the article, there are several studies that looked at folic acid consumption in women undergoing fertility treatment. The articles were from different countries (Germany, USA, Hungary and Norway) and all of them found that preconception use of folic acid was too low.

 What evidence is there that suboptimal care for diabetic patients undergoing fertility treatment is a widespread or international problem?
The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom published in December 2007 says, “that many of the women who died from pre-existing diseases or conditions which may seriously affect the outcome of their pregnancies, or which may require different management or specialised services during pregnancy, did not receive any pre-pregnancy counseling. In particular, this was the case for several women with major risk factors for maternal death who received treatment for infertility.”
 Conditions that should require pre-pregnancy counseling and advice, according to Maternal Deaths Report  include:
  • Epilepsy
  • Diabetes
  • Congenital or known acquired cardiac disease
  • Auto-immune disorders
  • Obesity BMI of 30 or more
  • Severe pre existing or past mental illness.
I think this statement highlights that the problem of inadequate medical evaluation and care prior to assisted reproductive technologies is probably universal. We have recently published an article (1) that recommends for medical evaluation prior to undergoing any assisted reproductive technology (just as is done before any surgery).

One would expect that a woman going through the difficult process of fertility treatments would be maximizing her chances of becoming pregnant and conceiving a healthy baby.  Does it surprise you that the results of your study don’t indicate this?

You are correct, but unfortunately this is not the case.  I was not very surprised since it matched my nonobjective observations in the high risk clinics.

What can be done to help women take better care of themselves? 

Diabetic patients should prepare themselves for pregnancy as outlined in the guidelines and more. This could be done in specialized high risk pregnancy clinics that also give preconception care or in specialized diabetic clinics that also give preconception care.  Receiving proper counseling is of utmost importance.

Karmel Allison contributed to this interview.

(1) Segev Y, Riskin-Mashiah S, Lavie O, Auslender R: Assisted reproductive technologies: medical safety issues in the older woman. J Womens Health (Larchmt ) 20:853-861, 2011

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Sharlin Stone

 
Thanks for your nice article. It is really providing great information to the readers. What are the Natural Medications to Increase Fertility with out any side effects? I have read about Natural Fertility Medication at hhttp://www.fertilitymedication.org/Natural-Fertility-Medication.html What do you think about this page?

Amy Stockwell Mercer

This is so discouraging to read! All it takes is access to education. This is an important and insightful article and we need to get the word out there……

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