Will selective serotonin reuptake inhibitors (SSRIs) help or hurt my chances of getting pregnant given my level of anxiety and obsessive-compulsive disorder (OCD) symptoms?

SSRIs Will Help More Than Hurt Your Chances of Getting Pregnant

For women with significant anxiety and OCD who are trying to conceive, continuing SSRI treatment is the right choice—untreated psychiatric illness poses greater risks to fertility and pregnancy outcomes than the medication itself. 1

Why SSRIs Are Beneficial for Fertility in Your Situation

Untreated Anxiety and OCD Reduce Fertility

• Depression and anxiety during pregnancy are associated with premature birth, decreased breastfeeding initiation, and reduced likelihood of conception, particularly in women undergoing fertility treatments 1
• Several observational studies support the use of SSRIs in women with depression or anxiety undergoing in vitro fertilization (IVF), as these medications effectively suppress psychiatric symptoms without relevant negative impact on IVF outcomes 2
• The psychiatric disorders themselves—not the medications—are what reduce the likelihood of becoming pregnant 2

SSRIs Have Minimal Direct Impact on Female Fertility

• While some experimental studies suggest paroxetine and escitalopram may affect fallopian tube motility, clinical evidence does not demonstrate that SSRIs meaningfully impair the ability to conceive in women 2
• Sertraline and citalopram should be first-line SSRI treatments for anxiety and OCD in women of childbearing age, as they have the most favorable safety profiles 3
• The concerns about SSRIs and fertility are primarily relevant for men (decreased sperm count and viability), not women 2

Treatment Approach for OCD During Conception Attempts

Medication Selection

• SSRIs are the first-line pharmacological treatment for OCD based on their established efficacy, tolerability, safety profile, and absence of abuse potential 1, 4
• Choose sertraline (50-200 mg daily) or citalopram as your SSRI, avoiding paroxetine and fluoxetine which have stronger associations with negative pregnancy outcomes 3
• Higher doses are typically required for OCD (often 150-200 mg daily for sertraline) compared to depression or anxiety alone 1, 4

Continuing Treatment Through Pregnancy

• SSRI treatment should be continued during pregnancy at the lowest effective dose, because withdrawal of medication may have harmful effects on the mother-infant dyad 1
• Women who discontinued antidepressant medication during pregnancy showed a significant increase in relapse of major depression compared to those who continued treatment 1, 5
• The decision to continue SSRIs during pregnancy should weigh the established benefits of treating your psychiatric condition against potential risks 1, 5

Understanding the Risks to Your Baby

Neonatal Adaptation Syndrome (Temporary and Self-Limited)

• Third-trimester SSRI exposure can cause temporary neonatal symptoms including irritability, jitteriness, feeding difficulty, and sleep disturbance 1
• These symptoms typically resolve within 1-2 weeks and do not cause long-term harm 1
• Several recent reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy 1

Other Pregnancy Considerations

• The risk of persistent pulmonary hypertension of the newborn (PPHN) remains unclear, with conflicting findings in the literature 1
• A recent meta-analysis suggested a number needed to harm of 286-351 for PPHN with late pregnancy SSRI exposure—meaning 286-351 women would need to take SSRIs for one case to occur 1
• There is no clear link between first-trimester SSRI use and cardiac malformations when properly controlled studies are examined 1

Practical Management Plan

Before and During Conception

• Continue your current SSRI at the lowest effective dose that controls your OCD and anxiety symptoms 1
• If not already on sertraline or citalopram, consider switching to one of these agents 3
• Ensure you're taking at least 8-12 weeks at an optimal dose to achieve full therapeutic benefit 4, 6

During Pregnancy

• Maintain SSRI treatment throughout pregnancy rather than stopping, as the risks of untreated illness outweigh medication risks 1
• Work with your obstetrician to arrange early follow-up after delivery, as infants may show temporary adaptation symptoms in the first week of life 1

Breastfeeding Considerations

• Sertraline can be continued during breastfeeding as the concentration in breast milk is very low and has not been linked to infant complications 3
• Paroxetine and sertraline are the most commonly prescribed SSRIs during breastfeeding, with paroxetine having the lowest infant-to-maternal plasma concentration ratios 1

Key Pitfalls to Avoid

• Do not discontinue your SSRI when trying to conceive or upon discovering pregnancy—this significantly increases your risk of psychiatric relapse, which poses greater risks to both you and your baby than continuing medication 1
• Avoid paroxetine and fluoxetine specifically, as these have the strongest associations with negative outcomes 3
• Do not use subtherapeutic doses out of fear—inadequately treated OCD and anxiety will harm your fertility and pregnancy outcomes more than appropriate medication doses 1, 2