Does oral contraceptive (OC) use cause infertility?

Oral Contraceptives Do Not Cause Infertility

No, oral contraceptive use does not cause infertility. The evidence consistently demonstrates that OC use has no substantial impact on long-term fertility, and may actually protect against certain causes of infertility.

Key Evidence on Fertility Outcomes

No Impact on Tubal Infertility

• Women using oral contraceptives show no substantial increase or decrease in risk of tubal infertility 1
• A large case-control study found that combined monophasic OC use was actually associated with a lower frequency of primary infertility, particularly among younger women (age ≤20 years) compared to older women (age ≥30 years) 2
• The multivariate relative risk for ovulatory causes of delayed fertility among ever-users of OCs was 1.2 (95% CI 0.7-1.9), which is not statistically significant, and 88% of cases reported an eventual pregnancy, indicating absolute fertility was not impaired 3

Temporary Delay vs. Permanent Infertility

• There is a temporary delay in return of fertility after discontinuation of oral contraceptives compared to other contraceptive methods, but this does not represent permanent infertility 3, 4
• After allowing for 2 years of suppressed fertility following OC discontinuation, no statistically significant trend of increasing risk was found with increasing duration of use or younger age at first use 3
• This delay may be concentrated in childless women aged 30-34, but does not affect ultimate fertility rates 4

Protective Effects Against Infertility

Reduced Risk of Pelvic Inflammatory Disease

• OC users have a lower risk of symptomatic, clinically overt PID, which is a major cause of tubal infertility 1
• While OC users have an increased risk of cervical C. trachomatis infection, they paradoxically have reduced symptomatic upper genital tract infection 1
• OCs may reduce the risk of PID that is not attributable to C. trachomatis 1

Comparison to Barrier Methods

• Barrier methods (condoms, diaphragms with spermicides) provide the clearest protection against tubal damage and infertility by preventing sexually transmitted infections 5
• Women who used barrier methods had a relative risk of 0.6 (95% CI 0.5-0.8) for tubal infertility 5
• However, OCs do not increase infertility risk compared to no contraception 2

Common Misconceptions

Patient Concerns Are Not Evidence-Based

• Nearly 50% of both current and past OC users incorrectly believe that OC usage could impair conception rates after discontinuation 6
• 28% of current users and 19% of past users mistakenly believe OCs could diminish ovarian reserve permanently 6
• Healthcare providers should proactively address these misapprehensions, as they are not supported by clinical evidence 6

No Relationship to Permanent Reproductive Dysfunction

• There is no relationship between oral contraceptive use and subsequent amenorrhea or pituitary adenomas 4
• OC use does not influence the overall rate of infertility in the population 4
• No increase in spontaneous abortion or pregnancy complications occurs after OC cessation 4

Clinical Implications

Counseling Recommendations

• Reassure patients that OC use will not cause permanent infertility based on decades of epidemiological evidence 3, 4, 2
• Explain that any delay in return to fertility after discontinuation is temporary and does not affect ultimate pregnancy rates 3, 4
• Address the common myth about "resting" the ovaries or taking breaks from OCs, as this has no medical basis 6

Special Populations

• For women with PCOS who are not attempting to conceive, combined oral contraceptives are recommended as first-line therapy and do not impair future fertility 7
• Women with a history of infertility should receive contraceptive counseling, as fertility may actually increase after certain medical treatments 1