For many people, antidepressants and anti-anxiety medications are helpful tools that improve their mental health. While there are countless factors to consider when someone is deciding whether antidepressants or anti-anxiety meds are right for them, there are even more factors to consider when that person may be trying to conceive (TTC) or pregnant.
When it comes to the use of antidepressants and anti-anxiety meds, there's an oft-cited belief that both are a problem while trying to conceive or pregnant. But is this reputation deserved? What do we actually know about the relationship between antidepressants and anti-anxiety meds and fertility? At a population level, there is no strong evidence that using antidepressant medication or anti-anxiety medication has a meaningful, harmful impact on someone’s ability to conceive or on their baby’s neonatal and long-term health. Ultimately, explains OB-GYN and Modern Fertility medical advisor Dr. Eva Luo, MD, MBA, "whether to continue the medications should be a discussion with your OB-GYN on the risks and benefits."
In this post, we’ll go over what implications (if any) using these medications has if you're trying to conceive, if you’re someone with eggs or someone with sperm, and if you’re currently pregnant.
- The most commonly used antidepressant (SSRIs) and anti-anxiety (benzodiazepine) meds don’t have any clear, long-term impacts on eggs or sperm, though SSRIs have short-term effects on sperm.
- Studies on the link between these meds and pregnancy outcomes have been mixed. While there may be small effects of SSRI and benzodiazepine use during pregnancy on some pregnancy outcomes, these effects are likely not clinically significant.
- SSRIs and benzodiazepines aren’t associated with an increased risk of birth defects or problems with fetal development.
- Health and medical bodies like the FDA, APA, and ACOG recommend that people do not change their SSRI or benzodiazepine use during pregnancy. Those who wish to do so should consult with their healthcare provider.
- Everyone’s situation is different, so it’s important to weigh the risks and benefits for your given situation when deciding whether to continue or discontinue these meds during pregnancy.
What are the effects of antidepressants and anti-anxiety meds on the brain and the body?
Different prescription medications for depression and anxiety work in different ways. For this article, we’ll focus on selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines because they're the two classes of drugs most commonly prescribed for depression and anxiety (another one you might have heard of is selective norepinephrine reuptake inhibitors, or SNRIs) — and they've had the most research conducted on potential links with reproduction and fertility:
1. Selective serotonin reuptake inhibitors (SSRIs): SSRIs like citalopram (Celexa), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft) primarily work by making more serotonin available in the brain, and the idea is that more serotonin binding in the brain leads to less depressive symptomatology. SSRIs also indirectly increase the activity of gamma aminobutyric acid (GABA), which you can think of as our naturally produced “chill out” neurotransmitter.
2. Benzodiazepines: Benzodiazepines like lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium), and alprazolam (Xanax) work by directly upping GABA activity. Increasing GABA has other effects in the brain beyond being helpful for depression and anxiety:
- Research in rodents has found that things that increase GABA activity decrease the activity of the hypothalamus, which sits at the very top of the reproductive hormone production pathway.
- Dampened hypothalamus activity may lead to lower luteinizing hormone (LH) levels and fewer mature eggs in rodents, and it’s observations from these studies that likely form the basis of the concern about SSRI and benzodiazepine use on fertility.
It’s also true that no organ exists in isolation, and SSRIs and benzodiazepines travel throughout the body when ingested and have effects on other systems. The fact that these drugs can potentially affect a range of bodily systems is likely also part of the reason people think they can affect pregnancy and fetal development.
Does taking antidepressants and anti-anxiety meds affect fertility in people with ovaries?
There is little evidence to suggest SSRIs and benzodiazepines affect egg quantity, egg quality, ovulation, or chances of conception in people with ovaries:
- Several studies of people using assisted reproductive technology (ART) like in vitro fertilization (IVF) to conceive suggest no effect of SSRI use on hormone levels, number of eggs retrieved, number of eggs that develop into blastocysts, number of embryos rated as "high quality," or number of embryos transferred. These studies have also not found statistically significant differences in pregnancy rates and live birth rates when comparing people who did and didn’t take SSRIs.
- While we have fewer studies to look to when assessing the potential impact of SSRIs on fertility outside the context of ART, the studies we do have also suggest no negative impact of SSRIs. A study of almost 1,000 people with ovaries found no differences in menstrual cycle characteristics as a function of SSRI use, and no significant differences in pregnancy rates. Other larger studies have mirrored these findings, and report no differences in chances of conception between people using or not using SSRIs or benzodiazepines.
- Some (but not all) studies find that SSRIs increase prolactin, and very high prolactin levels may suppress ovulation. That being said, even the studies that do find a link between SSRI use and prolactin levels don’t find that prolactin levels are elevated to a high enough point to affect ovulation.
Putting it all together, we don’t have compelling reason to believe SSRIs and benzodiazepines affect ovarian function or chances of conception. However, there is one sneaky, indirect way these meds could impact chances of conception in people with ovaries — by lowering your sex drive:
- In the context of unassisted reproduction, having sex less frequently within your fertile window could mean a lower chance of conception (the general rec is to have sex every 1-2 days in that window).
- The extent to which antidepressants and anti-anxiety medications affect sexual function differ across people and across medications. Someone on one type of SSRI might feel no effect but see their sex drive take a hard hit on a different type; others might not feel any effects on any meds.
- If this is something you’re concerned about, it’s worth bringing up to your mental healthcare provider.
Does taking antidepressants and anti-anxiety meds affect fertility in people with sperm?
While we don’t have much reason to believe SSRI or benzodiazepine use affects fertility in people with eggs, we can’t say the same for people with sperm. In this case, we do have data showing negative effects of meds (specifically SSRIs) on metrics of male fertility:
- SSRI use has been linked to lower sperm count, decreased motility, and higher DNA fragmentation (aka breaks in DNA), all of which can lead to lower chances of conception. The data on this point to these effects being reversible, meaning if any of these parameters were negatively impacted by SSRI use, we’d expect them to go back to baseline after stopping SSRIs.
- Just as sexual function may be affected by SSRIs in people with ovaries, the same holds for people with sperm — they may experience decreased sex drive, issues with ejaculation, and erectile dysfunction.
We don’t have as much data on benzodiazepines and semen parameters, so it isn’t clear whether they have that same transient, negative effect that SSRIs likely have. We do know, however, that they’re also associated with decreases in sex drive and sexual function, making it possible that benzodiazepines may decrease chances of conception in that sneaky indirect way.
Does taking antidepressants and anti-anxiety meds affect pregnancy and neonatal health?
Though there’s no shortage of human studies on links between SSRIs, benzodiazepines, pregnancy outcomes, and neonatal health, it’s important to acknowledge two huge caveats of these studies before diving into their findings:
- All these studies are observational, meaning they’re looking for links between medication use and the outcome. People aren’t randomly assigned to a study group and given either a real medication or placebo, as they would be in gold-standard randomized controlled trials, because this would be unethical. This means based on the available data we have in humans, we can make statements about whether SSRIs and benzodiazepines are linked with adverse outcomes, but we can’t make confident statements about whether those meds cause those outcomes.
- Taking medication use out of the equation entirely, there are studies finding links between untreated depression and anxiety and adverse pregnancy outcomes. This makes the effect of medications hard to parse out. If we compare pregnancy outcomes in people without depression or anxiety to those in people on medication for depression or anxiety, how could we be sure that any differences are a result of the medication or the underlying condition? The answer is, we couldn’t be. One way to get around this is to compare pregnancy outcomes in a group of people with diagnosed anxiety or depression, in which just a subset is taking medication. There are studies that do this (and we’ll talk about them below), but they aren’t the majority.
Now, given those caveats, onward to the data:
- A large meta-analysis on antidepressant use during pregnancy and pregnancy outcome found that there were small differences seen as a function of antidepressant use during pregnancy and gestational age, preterm birth, and Apgar scores (newborn health assessments soon after birth).
- There were no differences in rates of miscarriage or low birth weight as a function of medication use.
- These differences, or lack thereof, were seen when comparing people with depression not on meds to people with depression on meds, meaning we can surmise it might be the medications (and not the diagnosis of depression) that’s tied to those differences.
- Benzodiazepine use during pregnancy may also be linked to less favorable pregnancy outcomes like low birthweight or premature birth, as well as a small increase in spontaneous abortion rates.
- Most of these studies, however, don’t compare people with anxiety taking benzodiazepines to people without anxiety who aren't taking them. They instead compare them to people without anxiety — making it tricky to know whether the links we see are truly driven by benzodiazepines themselves.
For both SSRIs and benzodiazepines, there is no compelling evidence suggesting they negatively affect other aspects of fetal development. While anti-anxiety meds sold in the 1950s were definitively linked to severe fetal malformations (we're talking about thalidomide), the ones on the market today that people often take don’t have these effects.
Are the identified effects of SSRIs and benzodiazepines clinically significant?
Probably not. Just because differences exist as a function of benzodiazepine or SSRI use doesn’t necessarily mean these differences are clinically significant — in other words, anything that people should be concerned about. The differences researchers have detected are small in magnitude and are likely not changing patterns of medication use. In fact, the American College of Obstetricians and Gynecologists (ACOG), the American Psychiatric Association (APA), and the Food and Drug Administration (FDA) say that pregnant people shouldn’t stop their meds without first talking to a doctor (further underscoring the medical opinion that they're safe).
Are there any risks to going off antidepressants or anti-anxiety meds while pregnant?
The reality is that while pregnancy can be very exciting, it can also be a time of significant change (both in terms of your life and your body!), and it might come along with feelings of anxiety, depression, and stress. In those cases, your healthcare provider may recommend continuing the use of SSRIs or benzodiazepines. Here's why:
- People who abruptly discontinue SSRIs and benzodiazepines may experience a sudden increase in the symptoms that led them to start those medications in the first place — as well as new symptoms. (This is less common in people who taper down their doses over time.)
- There are also some important behavioral ramifications of severe untreated anxiety or depression during pregnancy — for example, these may make caring for or bonding with an infant more difficult and predispose someone to postpartum depression, which affects between 10%-15% of new parents.
"A depressed and/or anxious mom can be very harmful and dangerous," adds Dr. Luo. "I see so many patients who come to me with recurrence of symptoms after a primary care physician or psychiatrist told them to stop their medications due to concerns about the medications' effects on fertility or pregnancy."
For people currently on an SSRI or benzodiazepine who decide with their healthcare provider that the risks of continuing their meds during pregnancy outweigh the benefits, there are some alternatives they can explore to help manage their symptoms. Psychotherapy, mindfulness, acupuncture, and massage are just some of the things people may temporarily switch their meds out for. But remember: Always talk to your healthcare provider before making any changes to a prescription medication regimen.
Bottom line: Do what's right for you
The most commonly prescribed antidepressants and anti-anxiety meds don’t have long-term, clinically meaningful effects on fertility and pregnancy outcomes. That being said, we can’t say for certain that they don’t have any effects whatsoever. When making the decision of whether to continue or discontinue these meds if you’re trying to conceive or pregnant, it’s important to carefully weigh the potential risks and benefits (along with your healthcare provider) and make the decision that makes most sense for you and your well-being.
This article was medically reviewed by Dr. Eva Marie Luo, MD, MBA, OB-GYN at Beth Israel Deaconess Medical Center and Clinical Lead for Value at the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center.