Infertility is a problem which has gained increased attention over the past several decades. While many factors may contribute to infertility, some medications may also affect reproductive functioning and thus may have an impact on fertility. This post will focus on the antipsychotic drugs, which are now used to treat many psychiatric disorders other than schizophrenia, including insomnia, anxiety disorders, major depression and bipolar disorder.
Blockade of dopamine D2 receptors by antipsychotic agents can cause an increase in the levels of prolactin. Elevated prolactin levels (or hyperprolactinemia) can lead to irregular menstrual cycles and anovulation by altering levels of estrogen and FSH. Women with hyperprolactinemia may also experience decreased libido, galactorrhea (milk leakage from breasts) and possibly an increased risk for osteoporosis.
All of the older or typical antipsychotic agents, including haloperidol (Haldol), chlorpromazine (Thorazine), and perphenazine (Trilafon), increase prolactin levels. Among the newer or atypical antipsychotic drugs, risperidone is the most likely to cause hyperprolactinemia. For each of these agents, the level of hyperprolactinemia is dose-dependent. However, the prolactin level at which side effects occur is variable. In fact, even very small doses of an agent may cause significant side effects in certain individuals. Typically elevated prolactin levels range from 20-100 ng/ml (8ng/ml is normal). Anovulation and amenorrhea typically occur with a 15% increase in prolactin levels, galactorrhea with a 30% increase, and infertility with a 35% increase.
All patients treated with these prolactin-elevating agents should be questioned regarding their menstrual cycle patterns, and prolactin levels should be monitored on a regular basis. Should disruption of menstrual cycles occur, the dose may be reduced, if clinically feasible. With variable results, bromocriptine or amantadine may be used to lower prolactin levels. More helpful is likely switching to another atypical antipsychotic agent such as olanzapine, quetiapine, clozapine, aripiprazole, or ziprasidone. These appear to cause only minimal, brief elevations in prolactin.
It is important for patients to disclose their full medication lists to providers so that appropriate laboratory tests may be ordered and medication adjustments may be made. Hyperprolactinemia is a reversible cause of infertility. In addition, adjustments which solve this problem may prevent other, more invasive work-ups or procedures.
Kim Pearson, MD
Kornstein, SG, Clayton AH. Women’s Mental Health. The Guilford Press, New York. 2002.
Lebovic, DI, Gordon, JD. Reproductive Endocrinology & Infertility. Scrub Hill Press, Arlington. 2005.