Urinary selective serotonin reuptake inhibitors across critical windows of pregnancy establishment: a prospective cohort study of fecundability and pregnancy loss

Among selective serotonin reuptake inhibitor medications, the use of sertraline, citalopram, and escitalopram present the lowest risk for fecundability and early pregnancy loss in women trying to become pregnant.

VOLUME 114, ISSUE 6, P1278-1287


Lindsey A. Sjaarda, Ph.D., Jeannie G. Radoc, B.S., Kerry S. Flannagan, Ph.D., Sunni L. Mumford, Ph.D., Keewan Kim, Ph.D., Neil J. Perkins, Ph.D., Robert M. Silver, M.D., Enrique F. Schisterman, Ph.D.



To prospectively investigate the association of selective serotonin reuptake inhibitor (SSRI) exposure through critical windows of pregnancy establishment with fecundability and pregnancy loss.


Prospective cohort study using longitudinal urine measurements of common SSRIs while women are actively trying to conceive.


Four clinical sites.


A total of 1,228 women without uncontrolled depression/anxiety, attempting natural conception while participating in a randomized trial of preconception-initiated low-dose aspirin.


Not applicable.

Main Outcome Measure(s)

Urinary SSRIs (fluoxetine, sertraline, escitalopram/citalopram) were measured while trying to conceive and, for women who became pregnant, at weeks 0, 4, and 8 of pregnancy. Fecundability odds ratios and incidence of pregnancy loss and live birth were estimated.


A total of 172 women (14%) were exposed to SSRIs while trying to conceive. SSRI exposure was associated with 24% reduced fecundability, and accordingly, a nonsignificant 9% lower live birth incidence, with significantly lower live birth in fluoxetine-exposed women. SSRI exposure was not associated with subsequent pregnancy loss, whether exposure was before conception or at 0, 4, or 8 weeks of gestation, although estimates varied by specific SSRI drug.


Women using SSRIs may have more difficulty becoming pregnant, and although SSRI exposure overall was not associated with pregnancy loss, fluoxetine deserves caution and future study.

Clinical Trial Registration Number