Before assisted reproduction, build the pregnancy plan.
A focused MFM framework for IVF, ICSI, IUI, donor gametes, embryo transfer, and gestational carrier planning.
Chukwuma Onyeije, MD. Maternal-Fetal Medicine.
The best preconception visit answers one clinical question:
What should change before conception so pregnancy starts safer?
Use four passes, not a long lecture.
Reproductive plan
ART type, timing, embryo plan, donor or carrier involvement, prior outcomes.
Maternal risk
Medical, surgical, obstetric, psychiatric, medication, and exposure history.
Genetic risk
Family history, carrier screening, PGT status, and diagnostic testing options.
Pregnancy plan
Early OB/MFM handoff, anatomy scan, fetal echo, placenta review, growth, testing.
Define the reproductive path before counseling risk.
IVF, ICSI, IUI, ovulation induction, frozen embryo transfer, donor gametes, donor embryo, or gestational carrier.
Cycle start, anticipated transfer, donor matching, legal steps, and whether optimization can happen before treatment.
Losses, ectopic pregnancy, preterm birth, preeclampsia, FGR, fetal anomaly, stillbirth, cesarean, or uterine surgery.
Family size, embryo number preference, risk tolerance, and what the patient most wants clarified today.
Preconception care is risk reduction before the positive test.
- Optimize diabetes, hypertension, thyroid disease, renal disease, autoimmune disease, cardiac disease, seizure disorder, and psychiatric illness.
- Review every prescription, over-the-counter medication, supplement, and herbal product.
- Update immunizations and screen for infections when indicated.
- Start folic acid and address nutrition, body weight, sleep, substance use, safety, and psychosocial context.
ACOG/ASRM Committee Opinion 762.
Four conditions change early pregnancy risk quickly.
| Condition | Preconception focus | Why it matters |
|---|---|---|
| Diabetes | Review A1c and complication screening. | Lower congenital anomaly risk when glycemia is optimized. |
| Hypertension | Check BP control and medication safety. | ACE inhibitors and ARBs require pre-pregnancy planning. |
| Thyroid disease | Check TSH when clinically indicated. | Untreated disease is linked with loss, preeclampsia, preterm birth, and fetal risk. |
| Autoimmune, renal, cardiac | Confirm stability and organ baseline. | Pregnancy planning depends on disease activity and end-organ status. |
For pregestational diabetes, A1c belongs in the first pass.
ACOG/ASRM cite HbA1c less than 6.5% as a preconception target to reduce congenital anomaly risk when safely achievable.
ACOG/ASRM Committee Opinion 762.
Do not wait until the first prenatal visit to reconcile medications.
Identify medications that protect maternal health and should not be stopped reflexively.
Coordinate changes for medications with pregnancy safety concerns before conception.
Stop teratogenic or nonessential exposures when an appropriate alternative exists.
Preconception genetic counseling creates time.
- Take a three-generation family history, including anomalies, intellectual disability, recurrent loss, hemoglobinopathies, and consanguinity.
- Offer carrier screening consistent with what would be offered during pregnancy.
- If both partners are carriers, review PGT-M, donor gametes, and prenatal diagnostic testing before treatment decisions are locked in.
Most ART pregnancies do well. The risk profile is still different.
Preeclampsia, cesarean delivery, placenta previa, placental abruption, and delivery planning complexity.
Prematurity, low birth weight, small for gestational age, perinatal mortality, and birth defects.
The counseling goal is one healthy child at a time.
- Discuss embryo number and transfer strategy with the REI team.
- Frame twins as a medical risk, not a shortcut.
- For ovulation induction or stimulation, clarify cancellation thresholds and multifetal risk before the cycle begins.
ASRM Committee Opinion on multiple gestation associated with infertility therapy.
PGT reduces uncertainty. It does not replace prenatal testing.
Offer prenatal genetic screening and diagnostic testing options regardless of PGT status.
Offer genetic counseling, especially with male factor infertility, known genetic conditions, or abnormal prior testing.
SMFM Consult Series #60, reaffirmed 2024.
When reproduction includes third parties, documentation is part of safety.
- Confirm infectious disease and genetic screening for donor sperm, donor egg, or donor embryo.
- Confirm legal and psychological counseling when indicated.
- For gestational carriers, document medical risks, benefits, alternatives, and intended-parent arrangements.
The preconception visit should hand off a pregnancy roadmap.
| Phase | Action |
|---|---|
| Positive test | Confirm location, dating, viability, medication safety, and chorionicity if multifetal. |
| First trimester | Discuss genetic screening and diagnostic testing options, including limitations after IVF. |
| Anatomy | Detailed ultrasound with placental location, placental shape, cord insertion, and vasa previa evaluation. |
| Later pregnancy | Third-trimester growth assessment, weekly testing by 36 weeks for IVF, and shared decision-making about 39-week induction. |
IVF alone is not the aspirin indication.
SMFM does not recommend low-dose aspirin for IVF as the sole indication for preeclampsia prophylaxis.
SMFM Consult Series #60, reaffirmed 2024.
A useful consult note ends with decisions, not a transcript.
ART plan, maternal risk factors, genetic issues, medication changes, and readiness for treatment.
Labs, referrals, medication changes, carrier screening, embryo transfer discussion, and follow-up timing.
Before treatment or transfer, confirm these six items.
- Reproductive plan and timing are clear.
- Major medical conditions are optimized or actively managed.
- Medication and exposure risks have been reconciled.
- Folic acid, immunizations, and indicated labs are addressed.
- Carrier screening, PGT status, and prenatal testing options are documented.
- Pregnancy surveillance plan is ready for handoff.
Guidance used for this deck
Committee Opinion No. 762: Prepregnancy Counseling. Fertility and Sterility, 2019.
Consult Series #60: Management of pregnancies resulting from in vitro fertilization. 2022, reaffirmed 2024.
Multiple gestation associated with infertility therapy. Committee Opinion, 2022.
Educational material. Individual care depends on patient history, local resources, and clinician judgment.