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Opioids and Reproductive Medicine: A Special Views and Reviews Section in Fertility and Sterility

Recognizing that the use and abuse of opiate medication increasingly has implications for reproductive specialists, the editors of Fertility and Sterility have assembled a suite of articles to appear in the August  issue addressing the risks of opioids to patients seeking fertility care, particularly women of reproductive age, 15 to 44- those who are most at risk for opioid accidents and addictions.

In Women and the Opioid Crisis: Historical Context and Public Health Solutions, Mishka Terplan, MD, MPH traces the history of the current opioid epidemic in the United States and discusses the ways in which women are particularly vulnerable. He notes that in 2015, almost 40% of women between 15 and 44 reported receiving at least one opioid prescription. Dr. Terplan recommends a multi-pronged approach to the crisis that includes responsible prescribing, overdose education and naloxone co-prescribing, increased access to addiction treatment, and regarding addiction from a public health perspective rather than as a matter of criminal justice.

In Screening, Brief Intervention, and Referral to Treatment for Opioid and Other Substance Use During Infertility Treatment, Tricia Wright, MD, MS finds that reproductive endocrinologists (REs) have an ethical and medical duty to screen patients for substance use disorders (SUDs), provide initial counseling and refer to specialized treatment as needed.  Substance use disorders are more common than many other conditions and disorders in women trying to conceive and the stress of infertility diagnosis and treatment can make patients vulnerable to anxiety and depression, increasing their risk of developing a SUD. Opioid use in particular affects the hypothalamic-pituitary axis, contributing to irregularities in the menstrual cycle and possible difficulties in conceiving. Dr. Wright advises that, as physicians who treat women who are planning to become pregnant, REs are well placed to help their patients avoid the consequences of SUDs in pregnancy, such as pre-term birth, low birth weight, birth defects, developmental delays, miscarriage and neonatal abstinence syndrome.

Surgeries to correct problems related to infertility have the potential to cause great pain- which is often treated with opioid medications.  Prabhu et al outline strategies to decrease patients’ exposure to opioids before and after medical procedures in Perioperative Pain Management Strategies Among Women Having Reproductive Surgeries. These include the use of nonsteroidal anti-inflammatory drugs, acetaminophen and other adjunctive medications and regional anesthetic blocks.

In Impact of the Opioid System on the Reproductive Axis, Botcher et al describe the role of endogenous opioids as neuromodulators in the central and peripheral nervous system and their activity in the female reproductive system, where they act on various parts of the ovary, including ovarian follicles and oocytes, and may have effects on the endometrium and myometrium. The authors suggest future research into endogenous opioids could provide insight into diseases of the female reproductive system- such as polycystic ovary syndrome- and lead to new treatments.

Emphasizing the importance of considering the unique needs of women who are pregnant or planning pregnancy, Hand et al discuss four overlapping domains of treatment for opioid use disorder: medication management, medical care, behavioral and mental health care, and psychosocial support: In Treatments for Opioid Use Disorder Among Pregnant and Reproductive-Aged Women.

ASRM President Richard J. Paulson, MD commented, “As the opioid epidemic has escalated, most reproductive medicine specialists continue to practice as if it is not a phenomenon relevant to their patients. But patient demographics for opioid misuse and for fertility treatment show a strong overlap. Adding opioid screening to patient assessment is an important step to improving patient care.  This Views and Reviews is essential reading for all clinicians treating reproductive age women and for those who are interested in research into endogenous opioids and new treatments for disorders of the female reproductive system.”


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