About 2 decades ago, researchers discovered that glucagon-peptide 1 (GLP-1) stimulates insulin secretion and can treat type 2 diabetes. Some of the physiological effects of this drug class that allow for glycemic control include delayed gastric emptying, enhanced satiety, and anti-inflammatory effects. Since their discovery, the scope of GLPs has expanded into treatment for obesity, sleep apnea, osteoarthritis of the knees, renal failure, and heart failure across a wide range of drug variations. The aim of this study is to review and evaluate the currently available data on GLP-1 agonist use for the treatment of obesity-associated reproductive dysfunction. This narrative review used targeted searches of terms including "GLP1," "GLP1 receptor agonist," and "GLP1 receptor" in combination with "female," "male," "reproduction," "fertility," "polycystic ovary syndrome," "PCOS," "oral contraceptives," "gastric emptying," "drug interactions," "major congenital anomalies," and "pregnancy" through March 1, 2025. Prescribing information from FDA drug labels was also reviewed. Obesity is strongly associated with reproductive dysfunction in both men and women, with well-documented hormonal, structural, and gamete cell effects. In men, obesity can cause problems like reduced luteinizing hormone, testosterone, semen volume, and sperm count. These can cause diminished fertility through increased inflammation and oxidative stress, and reduced connection between the hypothalamic-pituitary-gonadal axis. Early evidence suggests that GLP-1 improves these pathways, with preclinical research showing action on gonadotropin-releasing hormone and Kiss neurons, remodeling testicular architecture, reduced oxidative stress, and improved testosterone and gonadotropin levels. Clinical studies of men have shown increased luteinizing hormone and follicle-stimulating hormone, improved sexual function, and greater sperm quality. Women have GLP-1 receptors in their ovarian and uterine tissue, and animal models of PCOS show improvements in ovarian follicle development, steroidogenesis, estrous cyclicity, and inflammatory markers. In clinical studies of women with PCOS, GLP-1 agonists improve androgen profiles, increase SHBG, reduce ovarian volume, regulate menstrual cycles, enhance ovulation, and improve both spontaneous and assisted pregnancy rates. Observational data also suggest lower rates of gestational diabetes, hypertensive disorders, preterm birth, and cesarean delivery among women who used GLP-1 agonists before pregnancy, even when matched for BMI, implying additional benefits beyond weight loss. At the same time, preclinical toxicology demonstrates fetal harm, and weight loss during pregnancy is associated with adverse fetal outcomes, underscoring the need for careful preconception management. Current recommendations emphasize counseling on improved fertility potential, possible reduced oral contraceptive efficacy due to altered gastric emptying, and the need for reliable contraception during GLP-1 therapy. Most experts recommend discontinuing long-acting GLP-1 agonists 2 months before attempting conception, though this may lead to weight regain and loss of glycemic control, requiring individualized support. GLP-1 agonists may play a role in treating hypogonadism and infertility in obese men and potentially offer meaningful benefits for women with PCOS. Further research is needed to characterize paternal risks, evaluate GLP-1 effects in women with obesity without PCOS, determine weight-loss thresholds for reproductive benefit, and clarify whether GLP-1 agonists can be safely continued during pregnancy. Long-term registries and strategies to maintain weight after discontinuation will be essential to guide future clinical practice.
