Occupational exposure to chemical or biological agents may be harmful to workers’ reproductive health, inflict damage on the genetic material of the cells of male and female workers, or evoke adverse effects on their sexual function and fertility. Some chemicals and infectious agents may also be harmful to the pregnancy and hazardous to the foetus. Such agents are often referred to generally as 'reprotoxic substances'. They include a variety of potentially harmful chemical agents e.g. some solvents, metals, pesticides and other chemicals. Prevention of the harmful effects of occupational exposures requires assessment and management of reproductive risks in the workplace. European legislation obliges employers to ensure that the work environment is safe for the reproductive health of the workers, pregnant workers, and offspring.
Effects of occupational exposure on the reproductive system of men and women may become manifest as alterations in sex hormone levels, diminished libido and potency, menstrual disorders, premature menopause, delayed menarche, ovarian dysfunction, impairment of semen quality, and reduced male and female fertility. Toxic exposures can cause direct cell damage in the developing sperm and eggs. Maternal exposure during pregnancy may disturb foetal development by either directly or indirectly interfering with maternal, placental, or foetal membrane functions. Toxic exposures can induce many wide-ranging effects, e.g. foetal death, intrauterine growth retardation, preterm birth, birth defect, postnatal death, disturbances in cognitive development, and changes in immunological sensitivity, or childhood cancer. The mother's exposure at work to chemicals may also cause contamination of her breast milk.
Some chemicals with hormonal activity, so-called endocrine disrupters, may alter the function of the endocrine system and consequently cause adverse reproductive effects, e.g. poor semen quality and damaged reproductive tissues in men and some gynaecological medical conditions in women (endometriosis, benign noncancerous tumors and infections of reproductive organs). Many chemicals, such as polychlorinated organic compounds, pesticides, phthalates, bisphenol A, brominated flame retardants and heavy metals have been identified as being possible endocrine disrupters.
Difference in the timing, duration and dose of exposure may lead to different outcomes. Miscarriage or birth defects are the principal outcomes if exposure has occurred during the first trimester of pregnancy. Exposure later in pregnancy is more likely to shorten the duration of gestation, reduce birth weight and affect the development of the brain. A lower dose of a toxicant may cause birth defects, whereas a high dose may produce miscarriage or infertility.
Adverse effects on reproduction and development are often the result of exposure during the narrow, vulnerable periods of ovulation, formation of a mature sperm (spermatogenesis) and the formation of organs within the embryo (foetal organogenesis). Some effects may not become evident for years. For example, lead may gradually accumulate in maternal tissue only to be released during pregnancy or lactation. Some toxicants, such as antineoplastic agents (cancer chemotherapy drugs), may reduce the number of female germ cells, leading to a shortened reproductive life span.
Chemical exposure of both women and men may cause chromosomal abnormalities or gene mutations in the offspring. It may also disturb the development of the foetus through heritable changes (epigenetic mechanisms) in egg or semen cells, causing no change in the underlying DNA sequence of the organism; instead, non-genetic factors cause the organism's genes to behave (or "express themselves") differently. There is some evidence of epigenetic effects of paternal exposure that can impact on the pregnancy outcome, but human evidence is still not convincing 
Exposure to a reprotoxic substance may be related to either one or to many reproductive outcomes, depending on both the substance, timing (before or during pregnancy), duration of the exposure and the dose of the agent absorbed. Adverse reproductive effects of some chemical agents that have been reported in human studies are shown in Table 1.
Maternal occupational exposure to high levels of solvents may increase the risks of miscarriage, birth defect and low birth weight , , , . An increased risk of miscarriage has been observed among workers in manufacturing, dry cleaning, painting, shoe-making, pharmaceutical, audio speaker, semiconductor and laboratory industries. In some studies, exposure to solvents has also been related to preterm birth, neurobehavioral effects and childhood leukaemia , , . The main routes of exposure are via inhalation and through the skin. Most solvents pass through the placenta and can be excreted from the mother in her breast milk.
Some studies suggest that solvent exposure is associated with delayed conception in women, but the evidence for males is less convincing , , , . Menstrual disorders have also been observed in exposed women . In men, solvent exposure has been associated with reduced semen quality and altered hormone levels , . The limited evidence on the effects of paternal solvent exposure on pregnancy outcome is somewhat inconsistent. Some studies have indicated that solvent exposure in fathers may be associated with birth defects in their offspring , .
Particular solvents which have been associated with adverse effects in human studies include benzene, carbon disulphide, some glycol ethers and their acetates, tetrachloroethylene and toluene. Some other solvents, for example formamide and dimethylformamide, have induced adverse effects in animal experiments. Concomitant exposure to a mixture of solvents is common, making it difficult to determine the contribution of one solvent alone to the adverse reproductive effects.
Some specific solvents
Some glycol ethers and their acetates have been able to trigger adverse reproductive and developmental effects in animal species exposed by different routes of administration. In manufacturing workers, exposure to ethylene glycol ethers has been related to an increased risk of miscarriage, birth defects, reduced fertility and prolonged menstrual cycles , , , . In particular, exposure to 2-methoxyethanol and 2-ethoxyethanol has been associated with reduced semen quality in shipyard painters, metal casters, chemical industry workers and workers in the semiconductor industries. In the EU some glycol ethers and their acetates are classified as substances that may damage or are suspected of damaging fertility and the unborn child.
Glycol ethers are used in paints, inks, varnishes, and cleaning agents. The use of the most toxic glycol ethers has declined from the mid-1990s these being gradually replaced with less toxic glycol ethers. In line with this development, past exposure to glycol ethers was found to be associated with low sperm quality, whereas the glycol ethers in use in 2000 – 2001 did not seem to have any impact on human semen characteristics . However, in another study, occupational glycol ether exposure during the later years was related to low motile sperm count ].
Exposure to carbon disulphide which is used primarily in the production of viscose rayon, may produce adverse reproductive effects in males and females. Decreased libido and potency and altered sex hormone levels have been found in studies in male workers exposed to high levels of carbon disulphide . In women, menstrual disorders, including irregular cycles and unusual menstrual bleeding, have been reported. Dry-cleaning work with high level of exposure to tetrachloroethylene has been associated with an increased risk of miscarriage . There is limited evidence suggesting exposure can also reduce fertility.
An increased risk of miscarriage has been observed among shoe workers, audio speaker factory workers and laboratory workers exposed to toluene . Reduced fertility has been described for toluene exposure in women but not in men , . Toluene abuse during pregnancy can lead to serious adverse reproductive outcomes , but occupational exposure to toluene is clearly lower than the exposure situation in abusers. In some studies, benzene exposure has been found to increase the risk of miscarriage and decrease birth weight , , .
Lead, mercury and cadmium
There is historical data linking heavy maternal exposure to lead with reduced fertility and increased risk of miscarriage, and lead is still the most extensively studied metal exposure. In addition, animal and human studies of reproductive outcomes point to an adverse role for exposure to mercury and cadmium.
Occupational exposure to lead and lead compounds may occur in many industries (Table 1). Historically heavy maternal exposure to lead has been linked with increased risk of miscarriage but the evidence of the risks of current low occupational exposure levels is scarce. A study carried out by ECHA in 2019  summarised the health effects of lead and its organic compounds. The study states that only a few epidemiological studies have been performed on the association between paternal exposure to lead and adverse reproductive outcome. However, the results suggest an increased risk of spontaneous abortion, perinatal death and low birth weight following paternal occupational lead exposure and that signs of male reproductive toxicity appear at PbB levels above 400 μg lead/L blood . The effects of maternal lead exposure may impact the cognitive development of the child. As lead passes the placenta and is stored in bones, it is likely that maternal occupational exposure to lead could contribute to a decreased cognitive function of the child either during in utero development of the nervous system or during infancy as a consequence of release of lead stored in foetal bone during the pregnancy. Several studies come to the conclusion that lead affects cognitive function in children prenatally exposed to PbB levels ≤ 100 μg/L, with some studies providing evidence for effects at PbB levels ≤ 50 μg/L .
Exposure of pregnant and breastfeeding women to lead and its derivatives is prohibited under the EU Directive 92/85/EEC  if the exposure might jeopardise safety or health (annex II). Annexes I and II of the EU Directive 98/24/EC on the protection of the health and safety of workers from the risks related to chemical agents at work specify a limit value for a binding occupational exposure to inorganic lead and its compounds (0.15 mg/m3) and a binding biological limit value of 70 μg Pb/100 ml blood for lead and its ionic compounds. The same binding biological limit value of 70 μg Pb/100 ml blood for lead and its ionic compounds was added to directive 2004/37/EC on the protection of workers from the risks related to exposure to carcinogens, mutagens or reprotoxic substances at work by the amending directive 2022/431/EU.
In 2020 the Committee for Risk Assessment (RAC) issued an opinion the occupational exposure limits (OEL) for lead and its compounds  based on the above-mentioned study from ECHA (2019). In its opinion the RAC proposes the following OEL:
- OEL as 8-hour TWA:
- 4μglead/m3 (inhalable fraction) for lead and its inorganic compounds
- None for organic lead compounds
- Biological limit value (BLV):
- 150 μg lead/L blood for lead and its inorganic compounds
- None for organic lead compounds
- Biological guidance value (BGV):
- 45 μg lead/L blood
In addition, RAC states that both the BLV and BGV do not sufficiently protect against developmental toxicity. Therefore, the RAC recommends to add a qualitative statement in the Directive 98/24/EC that the exposure of fertile women to lead should be avoided or minimized in the workplace because the BLV for lead is not protective of the offspring of women of childbearing age 
Inorganic mercury is transferred to the foetus although it also accumulates in the placenta. Female occupational exposure to mercury may cause menstrual disorders, delayed conception, and increase the risk of miscarriage , . Animal experiments have provided some evidence of adverse effects on female and male fertility, and exposure to mercury vapor may cause fetotoxicity or other adverse reproductive outcomes , . Evidence on reproductive effects in men is limited but exposure to mercury has been reported to decrease sperm count and quality , and has also been linked with an increased risk of miscarriage.
Cadmium may act as an endocrine disruptor (endocrine disrupters may alter the function of the endocrine system and consequently cause adverse reproductive effects, e.g. poor semen quality and damaged reproductive tissues in men and some gynaecological medical conditions in women). Cadmium is known to accumulate in the placenta, which may decrease the transport of micronutrients, e.g. zinc, to the foetus . Cadmium has also been reported to affect semen quality. In animals, cadmium has shown embryotoxicity, teratogenicity, and adverse postnatal effects.
Welding fumes typically include many agents with potential reproductive toxicity, e.g. hexavalent chromium, nickel, cadmium, manganese, and carbon monoxide. Research data on the effects on reproduction is mainly of men. Earlier studies have reported an increased risk of infertility and reduced semen quality among male welders. Studies from the late 1980's suggested that mild steel welding, rather than stainless steel welding, could be hazardous . However, studies of delayed conception and of impaired semen quality from the mid-1990s, did not indicate impaired reproductive capacity among welders. The decline in exposure levels in Western countries may explain the positive development . However, the findings of one well-designed study indicated that spouses of stainless steel welders were at increased risk of suffering a miscarriage . Overall, the evidence on reproductive toxicity of welding is mixed and inconclusive.
Firefighting has been classified by IARC (International Agency for Research on Cancer) as possibly carcinogenic to humans (Group 2B) . But, the chemicals to which professional firefighters may be exposed at the scene of a fire could also lead to adverse reproductive effects. A cohort study of 4,710 past and present male Danish firefighters  found an increased risk of male infertility among the firefighters in comparison with a sample of employees. Furthermore, the increase in infertility seemed restricted to duration of time employed as a firefighter. As possible causes for the reduced male infertility, the study points primarily to exposure to heat (hyperthermia) and also to chemical agents. Examples of such chemicals include polychlorinated and polybrominated biphenyls, polycyclic aromatic hydrocarbons, benzene, trichloroethylene and vinyl chloride. These chemicals may be present at the scene of a fire as a result of the combustion or released through extinguishing agents or from the disintegration of building components such as ceilings and walls.
Human studies indicate that exposure to pesticides may be harmful for reproductive health. Both men and women can be exposed in agriculture and greenhouses. Pesticides enter the body mainly through the skin, but also via inhaled air or through ingestion. The name pesticides refers to herbicides, insecticides, fungicides and fumigants. The most common chemical groups are organophosphates, carbamates, and phenoxyherbicides. Some pesticides (e.g., carbaryl, benomyl, ethylenthiourea, maneb, zineb, thiram) have demonstrated reproductive and/or developmental toxicity in experimental animals.
There is some evidence that exposure to pesticides can reduce female fertility but the results are inconsistent. Exposure to pesticides may also increase the risk of birth defects, miscarriage, or foetal death. In most studies, the risk could not be attributed to any individual pesticide. However, exposure to biologically persistent chlorinated hydrocarbons has been linked to miscarriage . In particular, two studies using biological exposure measures found an increased risk of early pregnancy loss in women with a high serum level of preconception DDE, a metabolite of DDT, .
Maternal occupational exposure to pesticides seems to increase the risk of childhood leukaemia. Pesticide exposure has also been linked with other cancer types, e.g. lymphomas, cancer of the brain and nervous system, Wilm's tumor, and Ewing's sarcoma, but the increased risk may also be related to childhood exposure , . The findings for paternal exposure are inconsistent.
Today the pesticide dibromochloropropane (DBCP) is banned but previously it was used as a soil fumigant and nematocide, and it is now recognized as a major testicular toxin. Long-lasting severe exposure has caused irreversible sterility (azoospermia, no sperm) or oligospermia (too few sperm). Another fumigant with adverse effects on male reproduction, ethylene dibromide (EDP), has also been banned. Moreover, adverse effects on semen quality have been found for exposure to some herbicides e.g. 2,4-dichlorophenoxyacetic acid (2,4-D), alachlor and atrazine, and three insecticides, chlordecone (Kepone™), carbaryl, and diazinon , .
There is some evidence that exposure to the pesticides currently used in farming or greenhouses can be hazardous for male reproduction. Conflicting findings on the effects of male exposure on couple fertility and adverse pregnancy outcome may be related to the level and type of exposure which may vary considerably according to the type of work and also between geographical areas. For example, a prolonged time to become pregnant was observed among Dutch fruit growers , the findings among Finnish greenhouse workers provided limited evidence of reduced fertility , but in Denmark no difference in fertility was seen between exposed conventional farmers and unexposed organic farmers. In addition, some but not all studies have reported increased risk of miscarriage or birth defects in spouses of exposed men.
Several studies have shown an increased risk of miscarriage among women occupationally exposed to anaesthetic gases in operating theatres, delivery wards, dental offices and veterinary surgeries . In some of the studies, the exposure has also been related to birth defects and low birth weight , . Adverse reproductive outcomes have especially been found in situations when anaesthetic gases were delivered without a gas scavenging system which is the technique to remove exhaled and waste anaesthetic gases , . Efficient scavenging equipment, good ventilation and equipment for the administration of anaesthetics help to minimize the exposure levels at the workplaces.
With respect to the specific anaesthetic gases, halothane and nitrous oxide have been shown to both be fetotoxic and teratogenic in animals. Exposure to nitrous oxide, the only anaesthetic gas to have been studied separately in humans, has been associated with an increased risk of miscarriage, reduced birth weight and a longer time to become pregnant in dental nurses or midwives , . Concerning isoflurane and enflurane, an experts' committee concluded that the lack of human data precludes a reliable assessment of their effects, but there was sufficient animal data and it indicated that they should not be classified as reproductive toxicants .
Nurses and other hospital workers may be exposed to antineoplastic (cancer chemotherapy) drugs during the preparation, administration, nursing and cleaning activities. Exposure can also occur in laundries, pharmaceutical companies, veterinary clinics, home care and nursing homes. Handling of antineoplastic agents in hospitals has been associated with menstrual dysfunction, reduced fertility, miscarriage, premature birth, low birth weight, and birth defects of the offspring , , . It has to be remembered that many of these drugs are also carcinogens. However, no increase in the risk for miscarriage or birth defects was found in a study conducted in settings where safety measures had been adopted to protect the healthcare personnel against exposure to antineoplastic drugs. Exposure can be minimized by wearing protective garments and using protective equipment (for example closed infusion systems), adopting good work practices and increasing awareness of workers of the potential hazards. The risk of exposure is probably highest in the preparation of drug solutions, which requires specific prevention measures. Therefore, some countries have adopted a policy of transferring pregnant workers who would be required to prepare antineoplastic drug solutions to other jobs. Information on preventing exposure to antineoplastic and other hazardous drugs in health care settings is available.
Some drugs have known adverse effects on the development of the foetus. Pharmaceutical factory workers and nurses may be exposed to drugs and vitamins. Unfortunately there is limited data on the effects of occupational exposure. It is known that excess vitamin A is teratogenic in many species, and diethylstilbestrol (DES) is a known human reproductive hazard. Some sex hormones have induced masculinization of female foetuses and feminization of male foetuses in animal experiments. Azathioprine, cyclosporin A, and some antiviral agents, such as acyclovir, ganciclovir, ribavirin, and zidovudine have also induced adverse reproductive effects in animal experiments.
NIOSH (National Institute for Occupational Safety and Health - USA) publishes a list of hazardous drugs in healthcare settings . The current version dates from 2016 but a draft version dating from 2020, is also available . NIOSH lists the hazardous drugs in 2 tables. The first table contains drugs that are known to be a human carcinogen, and/or are classified by the IARC as “carcinogenic" or “probably carcinogenic. The second table contains hazardous that are not known to be carcinogenic but they exhibit other types of toxicity, most of them have adverse development and/or reproductive effects . A study (2021) commissioned by DG Employment  to investigate options for protecting workers from exposure to hazardous medicinal products estimated that almost 1.8 million workers in the EU are exposed to hazardous medicinal products. The study identifies nursing professionals as the largest single occupational group that is exposed (40%) followed by medical and pathology laboratory technicians (11%) and pharmacists (9%). Based on a thorough literature review the study identifies breast cancer, haematopoietic cancers and miscarriages as potential health effects associated with exposure to hazardous medicinal products at the workplace 
Other chemical agents
Exposure to carbon monoxide may occur in welding work, iron and steel foundries, the alimentary industry, and in smoking procedures, as well as in car repair and service stations where there may be car exhaust gases. Carbon monoxide is transported through the placenta and levels in the foetus can become higher than those in the mother’s blood. With connection with maternal carbon monoxide intoxications, there have been reports of premature birth, intrauterine deaths and brain injuries in the infant.
Some phthalates have been shown to adversely affect reproduction in laboratory animals, but human data on their effects is scarce. Exposure has been linked to hypospadias (a birth defect of the genitalia among male infants) and anti-androgenic effects in newborns, . Examples of tasks with potential exposure to phthalates include polyvinyl chloride (PVC) film manufacturing, PVC compounding, phthalate (raw material) manufacturing and work in rubber industries and nail-care salons. Other exposures that may have adverse effects on the reproductive health include bisphenol A, benzo(a)pyrene, brominated flame retardants, environmental tobacco smoke, ethylene oxide and polychlorinated biphenyls.
Infectious agents, like toxoplasmosis, listeriosis, rubella, herpes, varicella, hepatitis B and C, cytomegalovirus, human parvovirus B19 and human immunodeficiency virus, can cause foetal loss, foetal growth retardation, congenital anomalies, mental retardation or systemic disease . Most observations of reproductive risk are based on general population studies rather than on any particular occupational groups.
Hepatitis B and C, rubella virus, varicella zoster virus, and toxoplasma
Hepatitis B and C, and rubella virus constitute a risk to reproductive health, particularly among health care workers while especially veterinary staff may be exposed to toxoplasma. Non-immune pregnant personnel should not have to care for patients with measles, rubella, varicella or herpes zoster, as these viruses may harm the foetus. However, most of the workers already have immunity against the common viral diseases (e.g. varicella) or have been vaccinated against these viruses (e.g. rubella and measles). Hepatitis B virus (HBV) vaccination is recommended for all hospital staff at risk of contamination of blood or other secretions of HBV-positive patients. A vaccine is also available against varicella. The ways to prevent infectious diseases include safe work practices and providing alternative jobs or maternity leave for non-immune pregnant workers. According to the European Union directive (92/85/EEC), pregnant workers should not perform duties for which an assessment has revealed a risk of exposure to toxoplasma or rubella virus, unless they have been demonstrated to be adequately protected against such agents by immunization.
Cytomegalovirus and human parvovirus B19
Studies on cytomegalovirus and human parvovirus B19 have consistently revealed a higher risk of these infections among women with occupational contacts with children than in other women. About 30–60% of women of reproductive age are seronegative and susceptible to suffer infection. Viruses are transmitted from mother to foetus with a transmission rate of 25–50%. Unfortunately, no vaccinations are available against these viruses. Risk of both infections can be diminished by good basic hygiene, including hand washing.
Cytomegalovirus is the most common cause of congenital infection. Most infected children are asymptomatic. However, a minority of affected children can suffer long-term complications including neurologic diseases, learning disability, deafness and blindness.
B19 infection has been particularly elevated among nursery school teachers and women working with groups of children participating in after-school activities but also among elementary school teachers as compared with other pregnant women. B19 infection can cause foetal anemia that may lead to foetal accumulation of fluid, edema, underneath the skin of the foetus, especially in the neck and in body cavities (hydrops), miscarriage and intrauterine foetal death , .
EU directive 92/85/EEC requires employers to assess the health and safety risks to pregnant and breastfeeding workers, and if needed, to change working conditions or offer suitable alternative work . If this is not feasible, the worker should be granted leave in accordance with the national legislation. The EU has also developed guidelines for the assessment of hazardous agents and processes as well as on what preventive measures can protect pregnant and breast feeding workers from the adverse effects of occupational exposure.
Other legislation applicable to exposure to reprotoxic substances includes EU directive 2004/37/EC on the protection of workers from the risks related to exposure to carcinogens, mutagens or reprotoxic substances at work, EU directive 94/33/EC on the protection of young people at work and EU directive 98/24/EC on the protection of the health and safety of workers from the risks related to chemical agents at work.
Before one can conduct a proper risk assessment, agents that are potentially harmful to reproductive health and the offspring need to be identified at the workplace. Useful health and safety information on chemicals can be found on Safety Data Sheets (SDS), and some other sources, e.g. technical documentation or material from manufacturers. Safety Data Sheets usually provide information on the properties of the substance, the dangers to health, and guidance for the protection of workers. Essential health and safety information on chemicals can also be found on some on-line international databases, e.g. the International Chemical Safety Cards https://www.ilo.org/safework/info/publications/WCMS_113134/lang--en/index.htm, GESTIS https://gestis-database.dguv.de and ECHA https://echa.europa.eu/information-on-chemicals. It is recommended to seek expert advice on potential harmful agents and how to avoid the risks. Instructions are also available on assessing exposure to hazardous drugs at work, their safe handling, and developing workplace procedures for using equipment that functions to reduce exposure.
Some agents have been classified in the EU as known or suspected human reproductive toxicants. Based on the CLP regulation (Regulation 1272/2008/EC on classification, labelling and packaging of substances and mixtures ""), reproductive toxicants are classified as follows:
- Category 1A: Known human reproductive toxicant
- Category 1B: Presumed human reproductive toxicant
- Category 2: Suspected human reproductive toxicant
- Effects on or via lactation: evidence of adverse effects in the offspring due to transfer in the milk and/or on the quality of the milk and/or the substance is present in potentially toxic levels in breast milk.
This is indicated by hazard statements which can be found on the label and in the Safety Data Sheet. Hazard statements for reproductive toxicity are as follows:
- H360: May damage fertility or the unborn child
- H361: Suspected of damaging fertility or the unborn child
- H362: May cause harm to breast-fed children
For example, some glycol ethers and their acetates, carbon disulphide, carbon monoxide, toluene, some phthalates, bisphenol A, lead, mercury, benomyl, and maneb have been classified as substances that may or are suspected of damaging fertility and the unborn child.
All chemicals have to be classified by their hazards, suitably packed and labelled before placing them on the market. To ensure that chemicals placed on the market do not adversely affect human health or the environment manufacturers, importers and downstream users also have to comply with the provisions of REACH (Regulation 1907/2006/EC) on the Registration, Evaluation, Authorisation and Restriction of Chemicals ). REACH imposes the obligation to register any chemical placed on the market and manufacturers must identify and manage the risks linked to these chemicals. They have to demonstrate how the substance can be safely used, and they must communicate the risk management measures to the users. Under REACH several substances are banned from placing on the market or only under strict conditions (Annex XVII of REACH). For instance, reprotoxins such as benzene and mercury are restricted substances .
According to the EU directive 92/85/EEC risk assessment and management should also be done, if pregnant and breast feeding workers could be exposed to genotoxic or carcinogenic agents. Carcinogenic agents that may cause changes in the genetic material of the cell are considered harmful for the reproductive health because they may also induce changes in the cells of the developing foetus. For example, benzene has been classified as a substance that may cause cancer or genetic defects.
It is important to assess the magnitude, frequency and duration of exposure. Occupational hygienic measurements or biological monitoring can be used for assessing the level of exposure to chemical agents. The measuring results can be compared to Occupational Exposure Limits (OEL) that have been set to prevent occupational diseases or other adverse effects in workers exposed to hazardous chemicals. The OELs may not take reproductive effects into account and thus expert assistance will be needed in the risk assessment.
Preventing biologic risks is mandatory according to Directive 2000/54/EC , . Risk assessment for biological agents should consider the nature of the agent, how infection is spread, how likely contact is, and what control measures there are.
Both the employer and workers should be informed about risk assessment results. It is also important to inform women and men beforehand, for example during the pre-employment medical examination, of any potentially harmful occupational exposures and protective measures to prevent any adverse reproductive effects. Women should be advised to contact health services immediately after becoming pregnant or when planning to become pregnant. Research and prevention have mainly focused on the effects of maternal exposure and there is a lack of knowledge about the adverse effects on male reproductive system. However, there is an increasing volume of information highlighting the vulnerability of the male reproductive system. Thus, prevention should be directed to all workers.
The employer's duty is to protect the reproductive health of both male and female workers. Employers should take the necessary measures to prevent or reduce exposure to the level where no risk exists, if the risk assessment reveals a risk to a worker's pregnancy or her breastfeeding of the infant . In the case of male workers, special attention should be paid to those chemicals that are known to impair male fertility. Prevention or reduction of exposure of workers can be done in several ways in accordance with the widely recognised hierarchy of control, e.g.Eliminating or substituting hazardous chemicals for safe alternatives,
- Improving the work environment by collective protection measures, such as the enclosure of the emitting process, local exhaust ventilation, general ventilation, changing work tasks and habits into safe procedures
- Use of personal protective equipment
- Moving the pregnant worker to another job
- Granting leave to the pregnant worker in accordance with national legislation, if none of the above measures is feasible.
Examples on how to phase out harmful chemicals and replace them with safer alternatives or techniques to reduce adverse health effects can be found in the Substitution Support Portal (SUBSPORT). The portal includes case story database presenting practical real-case examples. For example, one of the case stories describes how printing inks based on organic solvents and used for the printing of plastic shopping bags were replaced by water-based inks in a company that manufactured plastic bags. This measure eliminated the need for toluene and 1-butanol in the printing process.
In most cases, infection risks can be avoided or minimised by adoption of simple control measures. These include using good basic hygiene practices (especially hand washing), preventing puncture wounds and cuts, avoiding exposure to sharp objects and protecting the skin. Suitable information, instructions and training should also be provided to the workers. The administration of available vaccines is recommended in risk occupations. However, pregnant women should not be immunized with live attenuated virus vaccines (e.g. mumps or measles). Many workers already have immunity against common contagious diseases. In the case of a major risk of exposure to a highly infectious agent, a non-immune pregnant worker should avoid exposure altogether. According to EU guidelines, the employer must ensure immunity testing (chickenpox, toxoplasmosis, parvovirus) for risk occupations, and job transfer or temporary leave during epidemics, if the pregnant worker has no immunity.
Some countries have specific legislation that intends to protect workers from reproductive health hazards in the workplace. For example in Finland, there is legislation that ensures special maternity leave for pregnant women. The Statute of Health Insurance Act includes a list of agents considered to be potentially harmful for pregnant women and guidelines have been issued on the levels of exposure that should not be exceeded during pregnancy. If safe work cannot be offered, the woman is entitled to special maternity leave and maternity allowance is paid by the Social Insurance Institution.
Research supports the importance of job adjustments in pregnancy and use of personal protective equipment. For example, pregnant women who experienced a change in work conditions following the use of a preventive measure (withdrawal from work or job reassignment) had lower risk of preterm birth than those who did not. Job adjustment in pregnancy was also associated with a reduced absence from work . Some studies also suggest that the risk of adverse outcome has been lower among pesticide exposed workers when protective equipment, such as gloves or a respirator, has been worn , .
The participation of women in the labour force is increasing but there is also evidence accumulating of the health effects from occupational exposure to reprotoxins. Therefore the European Commission has taken legislative steps to reduce work-related exposure to reprotoxins. An important milestone was the amendment to directive 2004/34/EC in 2022 which brought category 1A and 1B reprotoxic substances into the scope of the directive. As a consequence, directive 2004/34/EC was renamed the carcinogens, mutagens and reprotoxic substances directive, or CMRD. The amendment also stipulated that hazardous medicinal products containing one or several CMR fall under the scope of Directive 2004/37/EC. In order to further clarify which medicines are covered, the European Commission will elaborate a definition of hazardous medicinal products and an indicative list of hazardous medicinal products by April 2025. Furthermore, guidelines on preventive measures for the preparation, administration and disposal of hazardous medicinal products in the workplace will be issued.
The EU is also taking action to further protect human health and the environment as part of an approach to tackle pollution from all sources and move towards a toxic-free environment (Chemicals Strategy for Sustainability: Towards a Toxic-Free Environment (2020) . One of the priorities listed in the strategy is to tackle endocrine disruptors. The EU is taking steps to harmonise the criteria for endocrine disruptors and to strengthen workers’ protection by introducing endocrine disruptors as a category of substances of very high concern under REACH.
The OSH Strategic framework 2021 – 2027 includes the priority to update and expand the protection of workers exposed to reprotoxic substances. Several actions are listed. The inclusion of reprotoxins and hazardous medicinal products into directive 2004/37/EC has already been achieved. Other initiatives, such as the introduction of stricter binding limit values on lead based on the RAC opinion (see above), are still expected.
 Hage, M.L. & Frazier, L.M., 'Normal reproductive and developmental biology', In Frazier, L.M. & Hage, M.L. (Eds.) Reproductive hazards of the workplace, John Wiley & Sons, New York, 1998, pp. 3-23.
 Cordier, S., 'Evidence for a role of paternal exposures in developmental toxicity', Basic &Clinical Pharmacology & Toxicology, Vol. 102, 2008, pp. 176-181. Available at: 
 Lindbohm, M-L., 'Effects of parental exposure to solvents on pregnancy outcome', J Occup Environ Med, Vol. 37, 1995, pp. 908-914.
 Ha, E., Cho, S.I., Chen, D., Chen, C., Ryan, L., Smith, T.J., Xu, X. & Christiani, D.C., 'Parental exposure to organic solvents and reduced birth weight', Arch Environ Health, Vol. 57, 2002, pp. 207-214. Available at: 
 Chevrier, C., Dananché, B., Bahuau, M., Nelva, A., Herman, C., Francannet, C., Robert-Gnansia, E. & Cordier, S., 'Occupational exposure to organic solvent mixtures during pregnancy and the risk of non-syndromic oral clefts', Occup Environ Med, Vol. 63, 2006, 617–623. Available at: 
 Thulstrup, A.M. & Bonde, J.P., 'Maternal occupational exposure and risk of specific birth defects', Occup Med (London), Vol. 56, 2006, pp. 532-543.
 Wennborg, H., Bonde, J.P., Stenbeck, M. & Olsen, J., 'Adverse reproduction outcomes among employees working in biomedical research laboratories', Scand J Work Environ Health, Vol. 28, 2002, pp. 5-11. Available at: 
 Infante-Rivard, C., Siemiatycki, J., Lakhani, R. & Nadon, L., 'Maternal exposure to occupational solvents and childhood leukemia', Environ Health Perspect, Vol. 113, 2005, pp. 787-792. Available at; 
 Julvez, J. & Grandjean, P., 'Neurodevelopmental toxicity risks due to occupational exposure to industrial chemicals during pregnancy', Ind Health, Vol. 47, 2009, pp. 459-468. Available at: 
 Correa, A., Gray, R.H., Cohen, R., Rothman, N., Shah, F., Seacat, H. & Corn, M., 'Ethylene glycol ethers and risks of spontaneous abortion and subfertility', Am J Epidemiol Vol. 143, 1996, pp. 707-717.
 Sallmén, M., Neto, M. & Mayan, O.N., 'Reduced fertility among shoe manufacturing workers', Occup Environ Med, Vol. 65, 2008, pp. 518-524. Available at; http://oem.bmj.com/content/65/8/518.full.pdf+html
 Plenge-Bönig, A. & Karmaus, W. 'Exposure to toluene in the printing industry is associated with subfecundity in women but not in men', Occup Environ Med, Vol. 56, 1999, pp. 443-448. Available at; 
 Heck, J., He, D., Contreras, Z., Ritz., B., Olsen, J., Hansen, J., Parental occupational exposure to benzene and the risk of childhood and adolescent acute lymphoblastic leukaemia: a population-based study. Occupational and Environmental Medicine, 2019;76:527-529. Available at: https://oem.bmj.com/content/76/8/527
 Cho, S.I., Damokosh, A.I., Ryan, L.M., Chen, D., Hu, Y.A., Smith, T.J., Christiani, D.C. & Xu, X., 'Effects of exposure to organic solvents on menstrual cycle length', J Occup Environ Med, Vol. 43, 2001, pp. 567-575.
 Figa-Talamanca, I., Traina, M.E. & Urbani, E., 'Occupational exposures to metals, solvents and pesticides: recent evidence on male reproductive effects and biological markers', Occup Med (Lond), Vol. 51, 2001, pp. 174–188.
 Tas, S., Lauwerys, R. & Lison, D., 'Occupational hazards for the male reproductive system', Crit Rev Toxicol, Vol. 26, 1996, pp. 261-307. Available at: 
 Logman, J.F.S., de Vries, L.E., Hemels, M.E.H., Khattak, S. & Einarson, T.R., 'Paternal solvent exposure and adverse pregnancy outcomes: A meta-analysis', Am J Ind Med, Vol. 47, 2005, pp. 37–44. Available at: 
 Hooiveld, M., Haveman, W., Roskes, K., Bretveld, R., Burstyn, I. & Roeleveld, N., 'Adverse reproductive outcomes among male painters with occupational exposure to organic solvents', Occup Environ Med Vol. 63, 2006, pp. 538-544. Available at; 
 Cordier, S., Bergeret, A., Goujard, J., Ha, M-C., Aymé, S., Bianchi, F., Calzolari, E., De Walle, H., Knill-Jones, R., Candela, S., Dale, I., Cananché, B., de Vigan, C., Fevotte, J., Kiel, G. & Mandereau, L., 'Congenital malformations and maternal occupational exposure to glycol ethers', Epidemiology Vol. 8, 1997, pp. 355-363.
 Chen, P.C., Hsieh, G.Y., Wang, J.D. & Cheng, T.J., 'Prolonged time to pregnancy in female workers exposed to ethylene glycol ethers in semiconductor manufacturing', Epidemiology, Vol. 13, 2002, pp. 191-196.
 Hsieh, G.Y., Wang, J.D., Cheng, T.J. & Chen, P.C., 'Prolonged menstrual cycles in female workers exposed to ethylene glycol ethers in the semiconductor manufacturing industry', Occup. Environ. Med., Vol. 62, 2005, pp. 510-516. Available at; 
 Multigner, L., Ben Brik, E., Arnaud, I., Haguenoer, J.M., Jouannet, P., Auger, J. & Eustache, F., 'Glycol ethers and semen quality: a cross-sectional study among male workers in the Paris Municipality', Occup Environ Med, Vol. 64, 2007, pp. 467-473. Avaiable at; 
 Cherry, N., Moore, H., McNamee, R., Pacey, A., Burgess, G., Clyma, J.A., Dippnall, M., Baillie, H., Povey, A. & participating centres of Chaps-UK, 'Occupation and male infertility: glycol ethers and other exposures', Occup Environ Med Vol. 65, 2008, pp. 708-714. Available at; 
 Gelbke, H.P., Göen, T., Mäurer, M. & Sulsky, S.I., 'A review of health effects of carbon disulfide in viscose industry and a proposal for an occupational exposure limit', Crit Rev Toxicol, Vol. 39, Suppl 2, 2009, pp. 1-126.
 Doyle, P., Roman, E., Beral, V. & Brookes, M., 'Spontaneous abortion in dry cleaning workers potentially exposed to perchloroethylene', Occup Environ Med, Vol. 54, 1997, pp. 848-853. Available at; 
 Lindbohm, M-L., 'Effects of parental exposure to solvents on pregnancy outcome', J Occup Environ Med, Vol. 37, 1995, pp. 908-914.
 Wilkins-Haug, L., 'Teratogen update: toluene', Teratology, Vol. 55, 1997, pp. 145-151.
 Xu, X., Cho, S.I., Sammel, M., You, L., Cui, S., Huang, Y., Ma, G., Padungtod, C., Pothier, L., Niu, T., Christiani, D., Smith, T., Ryan, L. & Wang, L., 'Association of petrochemical exposure with spontaneous abortion', Occup Environ Med, Vol. 55, 1998, pp. 31-36. Available at; 
 Chen, D., Cho, S.I., Chen, C., Wang, X., Damokosh, A.I., Ryan, L., Smith, T.J., Christiani, D.C. & Xu, X., 'Exposure to benzene, occupational stress, and reduced birth weight', Occup Environ Med, Vol. 57, 2000, pp. 661-667. Available at; 
 Wang, X., Chen, D., Niu, T., Wang, Z., Wang, L., Ryan, L., Smith, T., Christiani, D.C., Zuckerman, B. & Xu, X., 'Genetic susceptibility to benzene and shortened gestation: evidence of gene–environment interaction', Am J Epidemiol, Vol. 152, 2000, pp. 693-700.
 ECHA - European Chemicals Agency, ECHA Scientific report for evaluation of limit values for lead and its compounds at the workplace, 2019. Available at: https://echa.europa.eu/documents/10162/68cf7011-9c04-2634-efa6-b712f1b34a85
 Council Directive 92/85/EEC of 19 October 1992 on the introduction of measures to encourage improvements in the safety and health at work of pregnant workers and workers who have recently given birth or are breastfeeding (tenth individual Directive within the meaning of Article 16 (10 of Directive 89/39/EEC)).Available at: https://osha.europa.eu/en/legislation/directives/sector-specific-and-worker-related-provisions/osh-directives/10
 Council Directive 98/24/EC of 7 April 1998 on the protection of the health and safety of workers from the risks related to chemical agents at work, Official Journal of the European Communities L 131 of 5 May1998. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:1998:131:0011:0023:EN:PDF
 RAC - Committee for Risk Assessment, Opinion on scientific evaluation of occupational exposure limits for Lead and its compounds, ECHA/RAC/A77-O-0000006827-62-01/F, 2020. Available at: https://echa.europa.eu/documents/10162/ed7a37e4-1641-b147-aaac-fce4c3014037
 Rowland, A.S., Baird, D.D., Weinberg, C.R., Shore, D.L., Shy, C.M. & Wilcox, A.J., 'The effects of occupational exposure to mercury vapour on the fertility of female dental assistants', Occup Environ Med, Vol. 51, 1994, pp. 28-34. Available at; 
 Lindbohm, M-L., Ylöstalo, P., Sallmén, M., Henriks-Eckerman, M-L., Nurminen, T., Forss, H. & Taskinen, H., 'Occupational exposure in dentistry and miscarriage', Occup Environ Med, Vol. 64, 2007, pp. 127-133. Available at; 
 Barlow, S.M. & Sullivan, F.M., Reproductive Hazards of Industrial Chemicals, Academic Press, London, 1982.
 Wirth, J.J. & Mijal, R.S., 'Adverse effects of low level heavy metal exposure on male reproductive function', Syst Biol Reprod Med, Vol. 56, 2010 pp. 147-167.
 Cordier, S., Deplan, F., Mandereau, L. & Hemon, D., 'Paternal exposure to mercury and spontaneous abortions', Br J Ind Med, Vol. 48, 1991 pp. 375-381. Available at; 
 Kippler, M., Hoque, A.M., Raqib, R., Ohrvik, H., Ekstroom, E.C. & Vahter, M., 'Accumulation of cadmium in human placenta interacts with the transport of micronutrients to the fetus', Toxicol Lett, Vol. 192, 2010, pp. 162-168.
 Bonde, J. P., Hansen, K. S., & Levine, R. J., Fertility among Danish male welders. Scandinavian Journal of Work, Environment & Health, 1990, 16(5), 315–322. Available at: http://www.jstor.org/stable/40965812
 Jensen, T.K., Bonde, J.P. & Joffe, M., 'The influence of occupational exposure on male reproductive function', Occup Med (London), Vol. 56, 2006, pp. 544-553.
 Hjollund, N.H.I., Bonde, J.P.E., Jensen, T.K., Henriksen, T.B., Andersson, A-M., Kolstad, H.A., Ernst, E., Giwercman, A., Skakkebæk, N.E. & Olsen. J., 'Male-mediated spontaneous abortion among spouses of stainless steel welders', Scand J Work Environ Health, Vol. 26, 2000, pp. 187-192.
 IARC - International Agency for Research on Cancer, IARC Monographs on the evaluation of carcinogenic risks to humans. Volume 98: Painting, Firefighting and Shiftwork, 2010. Available at: https://monographs.iarc.who.int/wp-content/uploads/2018/06/mono98.pdf
 IARC - International Agency for Research on Cancer, Monographs – Volume 132 Occupational exposure as a firefighter (under preparation). Retrieved 2 February 2022 from: https://monographs.iarc.who.int/iarc-monographs-volume-132/
 Petersen, K., Hansen, J., Ebbehoej, N., Bonde, J., Infertility in a Cohort of Male Danish Firefighters: A Register-Based Study, American Journal of Epidemiology, Volume 188, Issue 2, February 2019, pp. 339–346. Available at: https://doi.org/10.1093/aje/kwy235
 Sallmén, M. & Lindbohm, M-L., 'Pesticides, lead and solvents: pregnancy outcome and fertility', Tijdshrift voor bedrijfs - en verzekeringsgeneeskunde, Vol. 14, 2006, pp. 396-400.
 Gerhard, I., Daniel, V., Link, S., Monga, B., & Runnebaum, B. 'Chlorinated hydrocarbons in women with repeated miscarriages', Environ Health Perspect, Vol 106, 1998, pp. 675-681.
 Longnecker, M.P., Klebanoff, M.A., Dunson, D.B., Guo, X., Chen, Z., Zhou, H. & Brock, J.W., 'Maternal serum level of the DDT metabolite DDE in relation to fetal loss in previous pregnancies', Environ Res, Vol. 97, 2005, pp. 127-133.
 Venners, S.A., Korrick, S., Xu, X., Chen, C., Guang, W., Huang, A., Altshul, L., Perry, M., Fu, L. & Wang, X., 'Preconception serum DDT and pregnancy loss: a prospective study using a biomarker of pregnancy', Am J Epidemiol, Vol. 162, 2005, pp. 709-716.
 Wilms' tumor or nephroblastoma is a cancer of the kidneys that typically occurs in children, rarely in adults.
 Ewing's sarcoma is a malignant small, round, blue cell tumour. It is a rare disease in which cancer cells are found in the bone or in soft tissue. The most common areas in which it occurs are the pelvis, the femur, the humerus, the ribs and clavicle. Ewing's sarcoma occurs most frequently in teenagers and young adults.
 Infante-Rivard, C. & Weichenthal, S., 'Pesticides and childhood cancer: an update of Zahm and Ward's 1998 review', J Toxicol Environ Health B Crit Rev, Vol. 10, 2007, pp. 81-99.
 Wigle, D.T., Turner, M.C. & Krewski, D., 'A systematic review and meta-analysis of childhood leukemia and parental occupational pesticide exposure', Environ Health Perspect, Vol. 117, 2009, pp. 1505-1513. Available at; 
 Lähdetie, J., 'Occupation- and exposure-related studies on human sperm', J Occup Environ Med, Vol. 37, 1995, pp. 922-930.
 De Cock, J., Westweer, K., Heederik, D., Velde, E. & Kooij, R., 'Time to pregnancy and occupational exposure to pesticides in fruit growers in the Netherlands', Occup Environ Med, Vol. 51, 1994, pp. 693-699. Available at; 
 Sallmén, M., Liesivuori, J., Taskinen, H., Lindbohm, M.L., Anttila, A., Aalto, L. & Hemminki, K., 'Time to pregnancy among the wives of Finnish greenhouse workers', Scand J Work Environ Health, Vol. 29, 2003, pp. 85-93.
 Larsen, S.B., Joffe, M. & Bonde, J.P., 'Time to pregnancy and exposure to pesticides in Danish farmers. ASCLEPIOS Study Group', Occup Environ Med, Vol. 55, 1998, pp. 278-283. Available at; 
 Boivin, J-F., 'Risk of spontaneous abortion in women occupationally exposed to anaesthetic gases: a meta-analysis', Occup Environ Med, Vol. 54, 1997, pp. 541-548. Available at; 
 Bodin, L., Axelsson, G. & Ahlborg, G. Jr., 'The association of shift work and nitrous oxide exposure in pregnancy with birth weight and gestational age', Epidemiology, Vol. 10, 1999, pp. 429-436.
 Teschke,K., Abanto, Z., Arbour, L., Beking, K., Chow, Y., Gallagher, R.P., Jong, B., Le, N.D., Ratner, P.A., Spinelli, J.J. & Dimich-Ward, H., 'Exposure to anesthetic gases and congenital anomalies in offspring of female registered nurses', Am J Ind Med, Vol. 54, 2011, pp. 118-127. Available at; 
 System for the transport of exhaled and waste anaesthetic gases from the exhaust valve of an anaesthetic ventilator or anaesthetic breathing system into the atmosphere at a safe location away from the operating theatre.
 Rowland, A.S., Baird, D.D., Shore, D.L., Weinberg, C.R., Savitz, D.A. & Wilcox, A.J., 'Nitrous oxide and spontaneous abortion in female dental assistants', Am J Epidemiol Vol. 15, 1995, pp. 531-538.
 Shirangi, A., Fritschi, L. & Holman, C.D. 'Associations of unscavenged anesthetic gases and long working hours with preterm delivery in female veterinarians' Obstet Gynecol Vol. 113, 2009, pp. 1008-1017.
 Committee for Compound Toxic to Reproduction, Enflurane. Evaluation of the effects on reproduction, recommendation for classification, The Hague, 2002.
 Meijster, T., Fransman, W., Veldhof, R, Kromhout, H. 'Exposure to antineoplastic drugs outside the hospital environment', Ann Occup Hyg, Vol 50, 2006 pp. 657-664.Available at; 
 Shortridge, L.A., Lemasters, G.K., Valanis, B. & Hertzberg, V., 'Menstrual cycles in nurses handling antineoplastic drug', Cancer Nursing, Vol. 18, 1995, pp. 439-444.
 Dranitsaris, G., Johnston, M., Poirier, S., Schueller, T., Milliken, D., Green, E. & Zanke, B., 'Are health care providers who work with cancer drugs at an increased risk for toxic events? A systematic review and meta-analysis of the literature', J Oncol Pharm Pract, Vol. 11, 2005, pp. 69-78. Available at; 
 Fransman, W., Roeleveld, N., Peelen, S., de Kort, W., Kromhout, H. & Heederik, D., 'Nurses with dermal exposure to antineoplastic drugs: reproductive outcomes', Epidemiology, Vol. 18, 2007, pp. 112-119.
 Skov, T., Maarup, B., Olsen, J., Rorth, M., Winthereik, H. & Lynge, E., 'Leukaemia and reproductive outcome among nurses handling antineoplastic drugs', Br J Ind Med, Vol. 49, 1992, pp. 855-861. Available at; 
 Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Settings DHHS (NIOSH) Publication Number 2004-165. Available at; 
 Weaver, V.M. & Dailey, V.A., 'Pharmaceuticals', In Frazier, L.M. & Hage, M.L. (Eds.) Reproductive hazards of the workplace, John Wiley & Sons, New York, 1998, pp. 289-311.
 NIOSH - National Institute for Occupational Safety and Health, NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016. Available at: https://www.cdc.gov/niosh/docs/2016-161/default.html
 NIOSH - National Institute for Occupational Safety and Health, Draft - NIOSH List of Hazardous Drugs in Healthcare Settings, 2020. Available at: https://www.regulations.gov/document/CDC-2020-0046-0003
 Study supporting the assessment of different options concerning the protection of workers from exposure to hazardous medicinal products, including cytotoxic medicinal products. Study commissioned by DG Employment, Social Affairs and Inclusion and prepared by Malene Sand Jespersen, Lorenz Carl Wähler, Carsten Lassen, Peter G. Madsen, Stine Werbrouck, Frans Christensen, Paul Sessink (COWI), Hilary Cowie, John Cherrie, Will Mueller, and Ioannis Basinas (IOM), 2021. Available at: https://op.europa.eu/en/publication-detail/-/publication/f43015ec-a24f-11eb-b85c-01aa75ed71a1
 Norman, C.A. & Halton, D.M., 'Is carbon monoxide a workplace teratogen? A review and evaluation of literature', Ann Occup Hyg, Vol. 34, 1990, pp. 335-347.
 Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urinary meatus (the opening, or male external urethral orifice)
 Exposure to anti-androgens can disrupt the action of androgens in foetal life. Steroidal androgens regulate male sexual differentiation and any suppression of their effects in foetal life may have irreversible de-masculinizing effects later in life.
 Main, K.M., Skakkebaek, N.E., Virtanen, H.E. & Toppari, J., 'Genital anomalies in boys and the environment', Best Pract Res Clin Endocrinol Metab, Vol. 24, 2010, pp. 279-289. Available at; 
 Morales-Suárez-Varela, M.M., Toft, G.V., Jensen M,S., Ramlau-Hansen, C., Kaerlev, L., Thulstrup, A.M., Llopis-González, A., Olsen, J. & Bonde, J.P., 'Parental occupational exposure to endocrine disrupting chemicals and male genital malformations: a study in the Danish National Birth Cohort study', Environ Health, Vol. 14, 2011, pp. 3. Available at; 
 Hines, C.J., Nilsen Hopf, N.B., Deddens, J.A., Calafat, A.M., Silva, M.J., Grote, A.A.& Sammons, D.L., 'Urinary phthalate metabolite concentrations among workers in selected industries: a pilot biomonitoring study', Ann Occup Hyg, Vol 53, 2009, pp. 1-17. Available at; 
 Ekblad, U., 'Biological agents and pregnancy'. J Occup Environ Med, Vol, 37, 1995, pp. 962-965.
 Russi, M., Buchta, W.G., Swift, M., Budnick, L.D., Hodgson, M.J., Berube, D. & Kelafant, G.A., 'Guidance for Occupational Health Services in Medical Centers'. J Occup Environ Med, Vol. 51, 2009, pp. 1e18e.
 Valeur-Jensen, A.K., Pedersen, C.B., Westergaard, T., Jensen, I.P., Lebech, M., Andersen, P.K., Aaby, P., Pedersen, B.N. & Melbye, M., 'Risk factors for parvovirus B19 infection in pregnancy', JAMA, Vol. 281, 1999, pp. 1099-1105.
 Miller, E., Fairley, C.K., Cohen, B.J. & Seng, C., 'Immediate and long term outcome of human parvovirus B19 infection in pregnancy', Br J Obstet Gynaecol, Vol. 105, 1998, pp. 174-178.
 Enders, M., Weidner, A., Zoellner, I., Searle, K. & Enders, G., 'Fetal morbidity and mortality after acute human parvovirus B19 infection in pregnancy: prospective evaluation of 1018 cases', Prenat Diagn, Vol. 24, 2004, pp. 513-518.
 Guidelines on the assessment of the chemical, physical and biological agents and industrial processes considered hazardous for the safety or health of pregnant workers and workers who have recently given birth or are breastfeeding. Available at; 
 Council Directive 94/33/EC of 22 June 1994 on the protection of young people at work. Available at: https://osha.europa.eu/en/legislation/directives/18
 Regulation (EC) No 1272/2008 of the European Parliament and of the Council of 16 December 2008 on classification, labelling and packaging of substances and mixtures, amending and repealing Directives 67/548/EEC and 1999/45/EC, and amending Regulation (EC) No 1907/2006, Official Journal of the European Union L 353/1 of 31 December 2008. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2008:353:0001:1355:EN:PDF
 Regulation (EC) No 1907/2006 of the European Parliament and of the Council of 18 December 2006 concerning the Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH), establishing a European Chemicals Agency, amending Directive 1999/45/EC and repealing Council Regulation (EEC) No 793/93 and Commission Regulation (EC) No 1488/94 as well as Council Directive 76/769/EEC and Commission Directives 91/155/EEC, 93/67/EEC, 93/105/EC and 2000/21/EC, OJ L 396, 30 December 2006. Available at:http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32006R1907:en:NOT
 REACH, Restricted substances, Annex XVII. Available at: https://echa.europa.eu/substances-restricted-under-reach
 Directive 2000/54/EC of the European Parliament and of the Council of 18 September 2000 on the protection of workers from risks related to exposure to biological agents at work (seventh individual directive within the meaning of Article 16 of Directive 89/391/EEC). Available at: 
 EU-OSHA – European Agency for Safety and Health at Work, 'Risk assessments for biological agents'. E-facts No 53, 2010. Available at; 
 Substitution Support Portal (SUBSPORT) (no publishing date available). Retrieved on 5 June 2012, from: 
 Infection risks to new and expectant mothers in the workplace. A guide for employers. Advisory Committee on Dangerous Pathogens. HSE Books 2005. Available at; 
 Plante, R. & Malenfant, R., 'Reproductive health and work: different experiences', Journal of Occup Environ Med, Vol. 40, 1998, pp. 964-968.
 Croteau, A., Marcoux, S. & Brisson, C., 'Work activity in pregnancy, preventive measures, and the risk of preterm delivery', Am J Epidemiol, Vol. 166, 2007, pp. 951-965.
 Kristensen, P., Nordhagen, R., Wergeland, E. & Bjerkedal, T., 'Job adjustment and absence from work in mid-pregnancy in the Norwegian Mother and Child Cohort Study (MoBa)', Occup Environ Med, Vol. 65, 2008, pp. 560–566. Available at; 
 Abell, A., Juul, S. & Bonde, J.P.E., 'Time to pregnancy among female greenhouse workers', Scand J Work Environ Health, Vol. 26, 2000, pp. 131-136.
 Sallmén, M., Liesivuori, J., Taskinen, H., Lindbohm, M.L., Anttila, A., Aalto, L. & Hemminki, K., 'Time to pregnancy among the wives of Finnish greenhouse workers', Scand J Work Environ Health, Vol. 29, 2003, pp. 85-93.
 Directive (EU) 2022/431 of the European Parliament and of the Council of 9 March 2022 amending Directive 2004/37/EC on the protection of workers from the risks related to exposure to carcinogens or mutagens at work. Available at: http://data.europa.eu/eli/dir/2022/431/oj
 EU Commission, Chemicals Strategy for Sustainability: Towards a Toxic-Free Environment (2020). Available at: https://ec.europa.eu/environment/strategy/chemicals-strategy_en
 EU Strategic Framework on Health and Safety at Work 2021-2027. Available at: https://osha.europa.eu/en/safety-and-health-legislation/eu-strategic-framework-health-and-safety-work-2021-2027
EU-OSHA – European Agency for Safety and Health at Work, Summary: State-of-the-art report on reproductive toxicants, 2017. Available at: https://osha.europa.eu/en/publications/summary-state-art-report-reproductive-toxicants/view
EU-OSHA - European Agency for Safety and Health at Work, Workplace risks affecting reproduction — from knowledge to action. Workshop summary. Available at: https://osha.europa.eu/en/tools-and-publications/seminars/workplace-risks-affecting-reproduction-from-knowledge-to-action
EU-OSHA – European Agency for Safety and Health at Work, Research, Gender issues in safety and health at work — A review, 2003, Available at: http://osha.europa.eu/en/publications/reports/209
EU-OSHA – European Agency for Safety and Health at Work, Info sheet: Substitution of dangerous substances in the workplace, 2018. Available at: https://osha.europa.eu/en/publications/info-sheet-substitution-dangerous-substances-workplace
EU-OSHA – European Agency for Safety and Health at Work, Training course: Substitution of dangerous substances in workplaces, 2021. Available at: https://osha.europa.eu/en/publications/substitution-dangerous-substances-workplaces/view-0
EU-OSHA – European Agency for Safety and Health at Work, Info sheet: vulnerable workers and dangerous substances, 2018. Available at: https://osha.europa.eu/en/publications/info-sheet-vulnerable-workers-and-dangerous-substances
EU-OSHA – European Agency for Safety and Health at Work, Info sheet: Legislative framework on dangerous substances in workplaces, 2018. Available at: https://osha.europa.eu/en/publications/info-sheet-legislative-framework-dangerous-substances-workplaces
EU Commission, Study to collect recent information relevant to modernising EU Occupational Safety and Health chemicals legislation with a particular emphasis on reprotoxic chemicals with the view to analyse the health, socio-economic and environmental impacts in connection with possible amendments of Directive 2004/37/EC and Directive 98/24/EC, Final Report prepared for DG Employment, Social Affairs & Inclusion, 2019. Available at: https://op.europa.eu/en/publication-detail/-/publication/094387fb-da9a-11e9-9c4e-01aa75ed71a1/language-en/format-PDF/source-250185515
Frazier, L.M. & Hage, M.L., Reproductive hazards of the workplace, John Wiley Sons, Inc., New York, 1998.
ILO – International Labour Organisation (no date). Male and female reproductive health hazards in the workplace. Retrieved 07 July 2015, from: http://training.itcilo.org/actrav_cdrom2/en/osh/rep/prod.htm
CDC - Centers for Disease control and Prevention, Managing Hazardous Drug Exposures: Information for Healthcare Settings, 2020. Available at: https://www.regulations.gov/document/CDC-2020-0046-0004
BG RCI - Berufsgenossenschaft Rohstoffe und chemische Industrie - Merkblatt M 039 Fruchtschädigende Stoffe - Informationen für Mitarbeiterinnen und betriebliche Führungskräfte, 2021. Available at: https://downloadcenter.bgrci.de/shop/?query=Fruchtsch%E4digende+Stoffe&field=stichwort
WECF, Women and chemicals – the impact of hazardous chemicals on women. Available at: https://www.wecf.org/77912/