Listener question: I was on the Pill and I'm having trouble getting pregnant. Help. Did I ruin my fertility?
JJ, You’re definitely not alone in having concerns about the Pill’s effect on fertility and I hope this podcast episode and article help you exhale!
A 2019 Danish survey of over two thousand women who had used combined oral contraceptives (COCs), meaning various combinations found in estrogen-progestin container Pills, found that they also shared these worries:
- 66% of current users and 52% of past users had considered whether or not using the combined oral contraceptive pill (COC) could affect future fertility.
- Nearly 50% of both groups believed COC use could impair conception rates after discontinuation.
- The majority of these women believed the impairment was only temporary, but 26% of current and 23% of past users thought the chance to become pregnant could be persistently decreased beyond 3 months after discontinuation.
- 28% of current users and 19% of past users believed COC could diminish the ovarian reserve more permanently, while 14% of current and 11% of past users believed that lack of ovulation could ‘spare' the eggs.
- 22% of current users and 35% past users had heard, primarily from female friends, that a short break of 1-2 months during long-term COC usage was healthy.
Clearly, women are worried, and while there are certainly risks to taking the Pill, as I’ll be talking about in an upcoming episode, the data is overwhelmingly reassuring that you have not incurred lasting damage, and in fact, surprisingly, some research even suggests some potential benefits.
But I’m getting ahead of myself – let’s review a tiny bit about what the Pill does, and also why women are so concerned.
How the Pill (and Other Hormonal Contraceptives) Affect Ovulation
Perhaps the biggest concerns arise from the fact that, contrary to the myth we’re often told that the Pill “regulates” our menstrual cycle, in fact, the Pill suppresses our menstrual cycle, including the signals that come from the brain, that trigger ovulation. But wait, you say, I have a period every month when I’m taking the Pill. Guess again! That’s not a true period at all. It’s what’s called breakthrough bleeding and it’s due to placebo Pills built into your monthly cycle of taking synthetic hormones. When you’re on the placebo Pills, the levels of synthetic hormones in your system drop, leading to a bleed that mimics a period.
It’s the suppression of ovulation that becomes the focal point of whether OCs can have a lasting, and impairing impact on ovulation after you’ve discontinued taking the Pill, and thus fertility in the months – or even years – following hormonal contraceptive use.
And there is the reality that many of us do hear stories about periods and ovulation taking some time to return after our friend or sister has stopped taking the Pill – and this naturally makes us feel worried, particularly if we’re hoping to be able to stop using it and get pregnant in the next cycle or the next several.
Let’s look at what the data tells us about this.
Is Fertility Reduced After Discontinuing the Pill?
Many studies confirm what many women experience – that there is a delay in the return of fertility after coming off the Pill (and other hormonal methods). However, before you get worried here, studies also consistently confirm that this delay is slight, and it’s just temporary.
According to a large 2020 study using data from nearly 18,000 women in North America and Denmark (a big study by any standards!), women who had been using an OC saw a return to normal fertility after an average of 3 menstrual cycles. (Comparatively, for users of IUDs, the average was 2 cycles, for the ring it was also 3 cycles, for the patch, it was 4 cycles, and for the injection, it was 5-8 cycles.) And a year out from coming off of hormonal contraception – good news – Pill users are just as likely to have gotten pregnant as those who’d been using non-hormonal methods. A 2011 review of studies on various forms of reversible contraception demonstrated that after stopping OC, roughly 80% to 95% of women got pregnant within one year. Now that may sound like a long time, but that’s broadly in line with the one-year conception rate following discontinuation of barrier methods (i.e., condoms, diaphragm) or using no contraception. The median time to conception was 2.5–3 cycles.
A 2019 Swedish study used data from the Natural Cycles fertility tracking app to investigate this question: The researchers followed women who were using the app to track their cycles in order to become pregnant. Some of the women had been previously using the app in order to prevent pregnancy, while some had recently stopped using hormonal contraception (HC). The women formerly using fertility awareness got pregnant in an average of 2.3 cycles, compared to 3.7 cycles for the former HC users. And after 13 cycles, the former HC users had caught up such that there was no difference between the two groups.
Keep in mind that 3 months is the average – meaning that there are women who don’t see their fertility return until 6 months or even up to a year after discontinuing HC. It’s important to know that this temporary delay is expected, so that women can account for this possibility and adjust their timing for Pill discontinuation with time to conception, if they are coming off the Pill with the goal of getting pregnant right away. It’s also important to recognize this possibility so you don’t automatically assume you have a fertility problem, or get rushed into an infertility workup or treatments that you may not actually need and that might resolve spontaneously if you wait a little longer to see if if was just HC-induced delay in return to fertility.
Does Taking the Pill Ruin Your Fertility in the Long Run?
Apart from the temporary dip in return to fertility that might occur in the first few months, or less commonly the first year and change, after coming off the Pill, there’s no indication that there are lasting negative effects on fertility, even from long-term OC use. In fact, contrary to what you might expect, some, though not all studies, have found that women who have been on OC for many years actually have an easier time getting pregnant when they go off. For example, a 2013 Danish study that followed women who were trying to conceive over one year found that the women who had taken an OC for more than four or five years got pregnant more quickly than those who had used them for less than two years. Those who’d used an OC for more than 12 years had the highest rates of conception.
The main hypothesis to explain these findings is that since OC inhibits ovulation, perhaps it may prevent the depletion of follicles that naturally occurs over our lifetime, in effect “sparing” a woman’s eggs, extending her fertile years, and delaying menopause.
However, research testing this hypothesis has yielded conflicting results. A 2020 meta-analysis of 17 studies found that OC use was associated with modestly later menopause. But that included mostly cross-sectional and retrospective observational studies, which are prone to bias, while some prospective studies have found no association or even that OC use is associated with earlier menopause. A 2001 study found that women who had used high-dose OC – the kind that was common before the 1970s – for 3 years or more had an earlier age of menopause, while taking lower dose OC, which are much more common now, had no effect on menopausal age. A 2021 study that included over 100,000 women – the largest study to date to tackle this question – found that use of OC had no effect (positive or negative) on the risk of early menopause (defined as before the age of 45).
So why, in the survey I mentioned on OC users' concerns about fertility, did roughly a quarter of women think that OC could diminish ovarian reserve – the quantity and quality of a woman’s remaining eggs? This concern likely stems from research showing that anti-müllerian hormone (AMH), antral follicle count (AFC), and ovarian volume are lower in women using OC. (These tests are often used to predict ovarian reserve.) For example, a large 2020 study from Denmark found that AMH, AFC, and ovarian volume are all significantly reduced in COC users; and AMH and AFC, but not ovarian volume, were also lower in (progestin-only Pill) POP users.
However, it seems that these reduced markers are a temporary, reversible effect of being on the Pill, rather than reflecting a “true” low ovarian reserve. A 2019 small prospective Danish study was reassuring on this front: They followed women who had been using OC for an average of 8 years, testing them repeatedly over the first few months after they came off the Pill, and found that their ovarian reserve markers had returned to normal within 2 months.
As more and more women are delaying having kids and seeking out ovarian reserve testing to give them a sense of how many more fertile years they might have, it’s important to be aware that these tests may be falsely low while taking OC, so re-test after going off the Pill for a few months.
The fact that these tests aren’t reliable markers of ovarian reserve while using OC also points to one reason it might be useful to periodically go off OC if you’re using it long-term and still planning to have children in the future. As I mentioned earlier, when you’re on the Pill, your monthly bleed is not a true menstrual period, so you can’t rely on it as a “6th Vital Sign,” and changes you may otherwise experience were you cycling naturally, might go unnoticed. This can lead to early menopause (or primary ovarian insufficiency) going undiagnosed. It's not that long-term OC use caused premature ovarian aging, but it did mask it.
If you are a long-term Pill user, going off the Pill periodically and allowing a natural cycle to resume for a few months, may alert you to changes in your menstrual cycle that may point to a possible decline in ovarian function. So if you’re concerned, you might consider doing this once a year for a couple of months, particularly if you plan to conceive in the foreseeable future and have concerns, however, medically it’s not considered necessary to do this. And keep in mind, if you do discontinue your birth control method, make sure you’re using an alternative method, for example, condoms.
Does Taking the Pill in Adolescence Affect Future Fertility?
So many women are started on the Pill in their teens, and remain on them for a decade or longer. Unfortunately, the data on the impact of the Pill on future fertility, when started in adolescence, is not as robust yet as I would like it to be, nor considering how robust it should be considering how many teens are started on the Pill.
That Danish study I mentioned earlier, which found long-term OC use was generally associated with greater fertility did have one concerning finding: Compared to women who had started using OC when they were 21 or older, those who had first started it at younger ages, especially those below age 16, did demonstrate reduced fertility. They also found that those who’d used third and fourth generation OCs had a longer time to conception than those who had used second generation OCs.
Since this wasn’t a randomized controlled trial, it’s hard to know what’s going on here. Since teens are often put on the Pill not just for contraception, but often to “treat” menstrual pain, cycle irregularities, PCOS symptoms, heavy menstrual flow, etc., it’s very possible that we see this correlation simply because the women who started taking the Pill at younger ages were more likely to have underlying reproductive problems that are typically associated with fertility problems. In other words, it’s correlation, not causation. Unfortunately, the researchers couldn’t determine if that was the case in their study, since they didn’t have data about the reason the women had started OC at younger ages.
But some researchers have raised concerns that using OC in adolescence could have greater risks than taking it in adulthood because, at that age, menstrual cycle regularity is still being established in the hypothalamic-pituitary-ovarian (HPO) axis.
After a teen’s first period, it takes a couple years – or longer – and you may remember this from your own first menstrual cycles – for menstrual cycles to become regular. And even once she’s menstruating regularly, it typically takes several more years for her to be consistently ovulating during those cycles. Could suppressing the HPG axis with OC during this gradual maturation process interfere with normal development of the reproductive cycle and have long-lasting detrimental impacts on future fertility?
Unfortunately, we don’t have great data to go on. OC was tested in women in their 20s and 30s, not teens, and despite the many young women using OCs, there haven’t been large, population-based, prospective studies (let alone randomized trials) following women who took OC within a few years of menarche (the onset of their first period) to see if they develop the same menstrual cycle/ovulatory function, fertility, and reproductive lifespan as peers who never used OC or who first went on the Pill as adults. Authorities like the American College of Obstetricians and Gynecologists support the use of OC in teens and there’s no doubt that the ease and convenience the Pill offers sexually active teens in terms of reliable pregnancy prevention are clearly significant.
But I think we need more research to fully establish the safety of OC on the developing HPO Axis. In the meantime, I personally recommend erring on the side of caution and not starting our girls on the Pill for common symptoms that might otherwise be readily treated with a root cause approach – lifestyle, diet and nutrition, etc., or a non-hormonal therapy, counseling on other forms of contraception, including the IUD or condoms, taking a multivitamin if the do go on the Pill to offset some of the nutritional depletions associated with the Pill, and reserving use of HCs in teens for as needed medical support, and contraception when other methods aren’t practical for the individual teen.
If you did use OC during your teen years – as many women do – or your daughter has been on it – don’t assume the worst. That same Danish study found that the difference between fecundability (the likelihood of getting pregnant in any given menstrual cycle) between those who started on an OC under age 16 versus over 21 was very small, approximately 0.8 versus 1.
Can You Support Ovarian Health After Coming Off the Pill?
If you’ve come off the Pill or other HC, it’s completely reasonable to simply wait three months and see if your cycle returns, and becomes regular, on its own, in that first three months after stopping it.
If it does not, you can wait longer. But I do recommend a basic evaluation for an underlying condition, like PCOS or endometriosis, that may have been masked while on OC, particularly if you had suggestive symptoms prior to beginning the Pill, or have suggestive symptoms upon discontinuation. Severe cramps, heavy, skipped, or irregular periods, acne, weight gain, hair loss, or hair growth in unwanted places are just some of the symptoms that may indicate that you have an undiagnosed underlying condition whose symptoms were being masked while you were on the Pill. It’s also possible that a condition, for example, PCOS or endometriosis, emerged but was masked during the time you were on the Pill.
If you’re getting toward the end of your fertile years and still wish to conceive, consider discontinuing the Pill with plenty of time to allow for return to fertility, and if this is at all delayed, even for just a few months, then consider a fertility workup. If you discontinue the Pill and you don’t have a return to fertility within 13 months, even if you don’t plan to conceive soon, or at all, I do recommend to any woman who has been on the Pill for an extended amount of time, ovarian reserve testing to check that you don’t have premature ovarian aging that developed while on the Pill.
Ovulation is also about more than conception – it provides many protective effects, and it’s important to properly treat for primary ovarian insufficiency or premature menopause, as it can be accompanied by bone loss and other problems that occur in the absence of the optimal estrogen and progesterone production that occur with our menstrual cycles.
In a previous article I offered some nutritional, herbal, and lifestyle tips for supporting your hormonal and ovarian health after coming off the birth control Pill:
Here are 3 key takeaways:
- Replace missing nutrients. Hormonal birth control Pills can deplete the body’s stores of certain nutrients, including vitamins B2, B6, and B12; vitamins C and E; and minerals like magnesium, selenium, zinc, and folate. Vitamin D levels may also drop after coming off the Pill, so I recommend taking a high-quality multivitamin and vitamin D supplement ideally started while you’re on the Pill, or at least for several months before and continued for several months after you stop taking it, or continuing until you resume normal cycling.
- Maintain healthy blood sugar and insulin levels. Some limited research has linked oral contraceptive use with insulin resistance, which can impact ovulation and lead to symptoms of excess androgens (acne, hair loss, unwanted hair) if you do have PCOS.
- Support return to ovulation with targeted herbal supplementation. Vitex, also called chaste berry extract, regulates ovulation, increases fertility, and slightly increases estrogen, improves progesterone levels. Vitamin C may also improve ovulation and progesterone production and melatonin plays an important role in ovulation and ovarian health.
So back to the question of whether taking the Pill ruins your fertility. If you haven’t already, all the science behind this question strongly suggests you can exhale right now. Studies strongly support that most women will have a spontaneous return to fertility within the first few months after discontinuing OCs, and of those who don’t, most of the remainder will by 13 months post-Pill. If you are personally eager to conceive at a certain time, make sure to give yourself ample time in case you do have a longer return to fertility, and if you don’t experience this return in a timeframe that you’re comfortable, whether trying to conceive or not, it’s reasonable to see your health care provider for a workup for ovarian reserve, fertility, and to rule out any conditions that may have been suppressed or which may have arisen while you were on the Pill. And for all women, if you haven’t had a return to fertility after that 13-month point, unless you’re clearly menopausal, a workup is important to make sure there are no underlying issues that are keeping your cycle from returning.
And there are further resources for you. For example, my latest book, Hormone Intelligence, has a whole chapter on supporting ovarian health, ovulation, and fertility with guidance that’s relevant to anyone struggling with infertility, whether they came off the Pill or not, has chapters on PCOS, endometriosis and more. It’s got a whole chapter on getting your blood sugar ‘balanced,’ and it’s a wonderful deep dive into the wondrous world of seeing your menstrual cycle as a 6th Vital Sign, a barometer of your total health that you can use starting now, when trying to conceive, and even all the way into your beautiful experience of perimenopause and menopause.