Beyond cardiovascular risk: is 'normal' blood pressure too high for reproductive success?

The relationship between blood pressure (BP) and reproductive health is increasingly recognized as a clinically relevant and biologically plausible axis influencing fertility outcomes. Evidence from ART cohorts suggests that reproductive success may decline across a continuum of increasing BP, extending below conventional hypertensive thresholds. Observational studies have linked male prehypertension with impaired semen quality and reduced ART success, and maternal prepregnancy systolic BP with lower live birth rates, higher miscarriage risk, and a greater burden of hypertensive pregnancy complications. These findings raise a provocative question: are BP levels considered acceptable for long-term cardiovascular prevention also optimal for implantation, placentation, and live birth? This Opinion article argues that preconception BP should be considered a potentially informative reproductive vascular marker, while clearly distinguishing BP as a possible causal determinant from BP as a surrogate of underlying vascular-metabolic health. Potential mechanisms include endothelial dysfunction, impaired nitric oxide signalling, reduced uterine perfusion, vascular inflammation, and altered remodelling affecting both the maternal environment and gamete quality. At the same time, causality remains unproven because current evidence is predominantly observational and vulnerable to residual confounding. A focused research agenda is therefore needed to test whether preconception BP optimization can improve reproductive outcomes and to determine whether reproductive medicine requires endpoint-specific BP thresholds.