Planning a family or just becoming new parents? Here's what you need to know in the age of the fentanyl epidemic.

In the US, 1 in 6 women and 1 in 9 men of primary childbearing years (ages 15-44) are prescribed opioids annually (Flannagan et al., 2020). The most common opioids prescribed include hydrocodone, oxycodone, morphine, codeine, hydromorphone, oxymorphone, buprenorphine, methadone, tramadol, and fentanyl (Westhoff, 2019). Fentanyl is a synthetic opioid which is 50-100 times stronger than morphine (NIDA, 2024). Fentanyl is usually safe when it is prescribed by a doctor and taken as directed, but it is extremely addictive (Westhoff, 2019). Fentanyl is also manufactured illegally and is distributed in powder or tablet form, but it is more commonly added to other illicit drugs (i.e., fake prescription painkillers) because of its extremely high potency (Westhoff, 2019). This causes drugs to be cheaper to make, more potent (thus more addictive), and far more dangerous, unbeknownst to the consumer (Westhoff, 2019).

Often, people become addicted to fentanyl or a similar painkiller after they are prescribed it by a doctor, and begin to seek out illegally manufactured pills after their prescription runs out, which are sometimes laced with illicit fentanyl (Osmundson et al., 2019; Westhoff, 2019). Opioid-involved overdose and poisoning deaths rose from 49,860 in 2019 to 81,806 in 2022 (NIDA, 2024). Fentanyl’s involvement in prescription opioid drug deaths has also steadily increased since 2014 (NIDA, 2024).

Fentanyl & Female Fertility

Opioid use during pregnancy has adverse effects for both the mother and baby, but the effects of fentanyl by itself on pregnancy, or pre-conception are not as often discussed.

The interaction between opioids and parenting begins before conception. Unfortunately, research on female fertility and fentanyl use is limited. Recent studies have found that for women, long-term use of opioids such as fentanyl can decrease production of sex hormones (estrogen, progesterone), causing abnormal periods and irregular ovulation (Corsi & Murphy, 2021; de Vries et al., 2020). Over time, disruptions to cycle health may cause fertility problems or even infertility, which may require medical intervention for family planning (Corsi & Murphy, 2021). Negative mental and physical health symptoms were also reported among people with chronic opioid use, including fentanyl, such as low libido, mood changes, and vaginal dryness (Corsi & Murphy, 2021). These symptoms are necessary for a healthy sex life, which increases the likelihood of conception for couples planning a pregnancy (de Vries et al., 2020).

Fentanyl and Fertility: Sperm Quality’s Role in a Healthy Pregnancy

A large body of new research has emerged regarding sperm quality’s role in pregnancy outcomes and maternal health. For example, paternal alcohol intake and diet are associated with maternal pregnancy symptoms such as morning sickness; the healthier the father, the better the mother will feel early on in her pregnancy (Capelo et al., 2024). New research also indicates that overall sperm health often carries more responsibility for the likelihood of successful implantation and the chance of miscarriage than the mother’s egg does (Capelo et al., 2024).

While there is limited research on drug-specific effects on male fertility, opioid abuse, including fentanyl, can negatively affect male reproductive hormones and spermatogenesis (the process by which the body makes sperm), and is associated with an increased risk of reduced testicular volume and erectile dysfunction (Capelo et al., 2024; de Vries et al., 2020). Frequent and long-term fentanyl use lowers testosterone in men and can disrupt other hormonal signals that regulate testosterone production, which is an essential process for sperm production and quality (de Vries et al., 2020; Flannagan et al., 2020). Using fentanyl beyond the duration for which it was prescribed and using unprescribed fentanyl (illegally manufactured) can lead to reduced sperm motility (ability to swim), decreased sperm count and sperm concentration, changes in sperm morphology (sperm shape), and increased DNA fragmentation in sperm, all of which increase problems with getting a partner pregnant (Capelo et al., 2024; de Vries et al., 2020; Flannagan et al., 2020).

In addition to the mechanistic consequences of fentanyl use on sperm quality, opioid use also negatively impacts mental health, which has a direct association with libido and sexual performance (de Vries et al., 2020). Opioid use increases depression and anxiety symptoms, which are slightly higher in men with heavy substance use. These symptoms increase the risk of decreased sexual desire, opioid-induced sexual dysfunction (including orgasmic disorder), and overall lessened sexual satisfaction (de Vries et al., 2020).

Fentanyl Use During Pregnancy

There was a significant increase in maternal fentanyl use in pregnancy during the COVID-19 pandemic (Lien et al., 2023). Rates of depression and anxiety, including postpartum depression, also increased during the COVID-19 pandemic(Lien et al., 2023). Given its strength and potency, long-term and non-prescription fentanyl during pregnancy is linked to several risks for both the mother and baby, including preterm births and low birth weight, as well as preeclampsia and placental abruption (Osmundson et al., 2019). Some studies have shown associations between short-term opioid exposure during pregnancy, including fentanyl (defined as 1–29 days’ supply dispensed), and a higher risk of pregnancy loss among women 13 weeks pregnant or less. Long-term and unprescribed fentanyl use during pregnancy is also linked to stillbirth and sudden infant death syndrome [SIDS] (Flannagan et al., 2020).

Recent small-scale studies have reported novel syndromes in infants exposed to non-prescription fentanyl, including microcephaly, abnormal facial features, cleft palate, feeding difficulties, and congenital anomalies of the hands and feet (Wadman et al., 2023). Maternal fentanyl use during pregnancy can also lead to neonatal abstinence syndrome (NAS) in newborns, as fentanyl, a strong opioid, can cause withdrawal symptoms in infants after birth due to in-utero exposure (Peacock-Chambers et al., 2019; Wadman et al., 2023). Importantly,prescribed an opioid for a legitimate medical need, it can still cause NAS in a baby. Opioid antagonist therapy (OAT), the treatment for opioid use, can also lead to NAS, but research shows that it is still the best course for both the mother and baby’s health when prenatal opioid use is present (Peacock-Chambers et al., 2019; Peacock-Chambers et al., 2020). The good news is, NAS is treatable, so if someone takes opioids during pregnancy–whether prescribed or not, no need to panic.

Neonatal Abstinence Syndrome (NAS)

Neonatal abstinence syndrome (NAS) is a type of withdrawal syndrome that occurs in newborns exposed to substances in utero, most commonly opioids (Peacock-Chambers et al., 2019). Symptoms of NAS appear 24-72 hours after birth and include irritability/inability to calm, excessive crying, tremors, seizures, difficulty feeding, diarrhea, vomiting, fever, sleep disturbances, and hypertonia [stiffness and difficulty moving] (Peacock-Chambers et al., 2019). To treat NAS, babies are provided with a calm and quiet environment to help regulate their central nervous systems. They are given IV fluids, frequent feedings with high-calorie formula, gentle rocking, swaddling, and holding to provide comfort and promote bonding chemicals. They may also be given medications to reduce withdrawal symptoms, like morphine, methadone, and buprenorphine, especially when symptoms like seizures are present (Peacock-Chambers et al., 2019). The dosages for these medications are closely monitored and reduced as symptoms improve (Peacock-Chambers et al., 2019).

Fentanyl Use During Birth

In vaginal labor and deliveries where an epidural is used for pain relief, fentanyl is usually the opioid used to control pain (Osmundson, 2019). Additionally, in cesarean section (C-section) births, epidural fentanyl is often added to epidural local anaesthetic agents to improve the quality of anaesthesia obtained during Caesarean section. Fentanyl may be given either before or after delivery of the infant. The majority of newborn babies will test positive for fentanyl 24 hours after birth, but research indicates that no long-term risks or effects will linger from this exposure (Osmundson, 2019). This may be alarming to people given the fentanyl epidemic, but fentanyl used during epidurals and C-sections is considered safe for the mother and baby (Osmundson, 2019). Expectant parents should consult their doctors regarding any questions and should be open if they have concerns about previous opioid use histories.

Opioid Use in Postpartum

Studies estimate that 80% of C-section mothers and 54% of vaginal birth mothers are prescribed high-strength painkillers like oxycodone, morphine, and fentanyl for pain management during their recovery post birth (Corsi & Murphy, 2021; Osmundson, 2019). People with substance use histories are at an elevated risk of relapse following the birth of children, regardless of whether they carried their child or not [i.e., fathers] (Flannagan et al., 2020; Peacock-Chambers et al., 2020; Peacock-Chambers et al., 2019). Because women are commonly exposed to opioids after birth for pain management, their risk is unique, especially considering hormonal changes in their bodies post-birth (Osmundson, 2019; Peacock-Chambers, 2020). A recent study on mothers who gave birth via C-section revealed that 75% of recovered mothers had prescription opioids left over in their homes, which pose a risk of opioid misuse and addiction (Lien et al., 2023). Another recent study indicated that highly potent opioids are often still overprescribed for many women, even if they are not medically necessary (Corsi & Murphy, 2021). Doctors should exercise judicious clinical judgment in the dosage and duration that opioids are prescribed, especially for patients with substance use histories. New or expectant parents who are concerned about their risk of addiction and/or relapse can also be proactive by self-advocating for alternative pain management approaches and medication tapering plans to mitigate the risk of overuse.

The Take Home Points

Given that fentanyl is still frequently prescribed for recovery after surgeries and giving birth, it is critical that new parents are aware of the risks of addiction to opioids in the age of the fentanyl epidemic. Opioid misuse has serious and long-term consequences for fertility (both male and female) and sexual functioning. Opioid use in pregnancy can pose serious threats to the health of the mother and baby, and treatment for NAS is important if the baby has been exposed in utero. For new parents with substance use histories, discussing concerns openly with their doctor regarding relapse prevention can save lives.

If you or someone close to you is struggling with substance use, SAMHSA’s National Helpline, 1-800-662-HELP (4357) (also known as the Treatment Referral Routing Service), or TTY: 1-800-487-4889, is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations.

In crisis? Text or call 988.

References:

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Corsi, D., Murphy M. (2021). The Effects of opioids on female fertility, pregnancy and the breastfeeding mother-infant dyad: A Review. Basic Clin Pharmacol Toxicol. 128: 635–641. https://doi.org/10.1111/bcpt.13577

de Vries, F., Lobatto, D., Dekkers, O., Schoones, J., van Furth, W., Pereira, A., Karavitaki, N., Biermasz, N., Najafabadi, A. (2020) .Opioids and Their Endocrine Effects: A Systematic Review and Meta-analysis, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 4, Pages 1020–1029, https://doi.org/10.1210/clinem/dgz022

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