According to Canadian guidelines, at what time should a fertility work‑up be initiated in couples and what are the indications for earlier referral?

Timing of Fertility Work-Up According to Canadian Guidelines

In Canada, initiate a fertility work-up after 12 months of regular unprotected intercourse for women under 35 years, but expedite evaluation to 6 months for women aged 35 years or older. 1, 2

Standard Timeline for Initiating Evaluation

Women Under 35 Years

• Begin formal infertility assessment after 12 consecutive months of regular, unprotected intercourse without achieving pregnancy 1, 2
• This 12-month threshold represents a strong recommendation endorsed by major guideline organizations 1
• Approximately 15% of couples will meet this definition and require medical assistance 1

Women 35 Years and Older

• Expedite evaluation to 6 months of attempted conception rather than waiting the full 12 months 2, 3
• This earlier timeline is justified because age-related fertility decline significantly reduces treatment success rates if evaluation is delayed 1, 2
• Women over 40 years warrant immediate evaluation and treatment without waiting 3

Indications for Immediate or Earlier Evaluation

Do not wait the standard 12-month period in the following clinical scenarios:

Menstrual Irregularities

• History of oligo-amenorrhea (infrequent or absent menstruation) warrants immediate evaluation 1, 2
• Suspected ovulatory dysfunction requires prompt assessment 2

Known Structural or Pathologic Conditions

• Known or suspected uterine disease (congenital anomalies, fibroids affecting the cavity) 1, 2
• Known or suspected tubal disease (history of pelvic inflammatory disease, ectopic pregnancy) 1, 2
• Endometriosis diagnosis or strong clinical suspicion 1, 2
• History of salpingitis from chlamydia infection or other sexually transmitted infections 4

Male Partner Factors

• Partner with known subfertility or abnormal semen parameters 2, 4
• Previous vasectomy or known reproductive issues 2

Medical History Red Flags

• Previous pelvic surgery or severe pelvic infections 4
• History of cancer treatment (chemotherapy or radiation) 2
• Genetic conditions known to affect fertility 2

Critical Evaluation Strategy

Simultaneous Partner Assessment

• Both partners must be evaluated concurrently from the outset—this is a strong recommendation 1, 2
• Male-associated factors contribute to approximately 50% of infertility cases, making isolated female evaluation inadequate 1
• Concurrent evaluation prevents diagnostic delays and avoids unnecessary interventions focused solely on one partner 1

Initial Male Partner Evaluation

• Obtain reproductive history and perform physical examination 2
• Order semen analysis with at least two samples, one month apart 2
• Male factor accounts for 26% of known infertility causes 1

Initial Female Partner Evaluation

• Comprehensive medical and reproductive history including duration of attempted pregnancy, coital frequency and timing, menstrual history, previous pregnancies, and medical conditions associated with reproductive failure 2
• Physical examination: height, weight, BMI calculation, thyroid examination, clinical breast examination, assessment for androgen excess, and complete pelvic examination 2
• Ovarian reserve testing with follicle-stimulating hormone (FSH) levels 2
• Transvaginal ultrasound to evaluate uterine anatomy and assess for tubal patency and pelvic pathology 2
• Document ovulation with serum progesterone on cycle day 21 or home urinary luteinizing hormone kits 2

Common Pitfalls to Avoid

Age-Related Delays

• Never postpone evaluation in women ≥35 years by waiting the full 12 months—this compromises treatment success 1
• Women over 40 require immediate intervention without any waiting period 3

Incomplete Partner Assessment

• Never limit assessment to the female partner alone, as this delays diagnosis in half of all cases 1
• Failing to assess both partners simultaneously is the most common cause of delayed diagnosis 2

Secondary Infertility Assumptions

• Do not assume fertility based on prior successful pregnancies 1
• Secondary infertility (affecting 1 in 6 couples attempting subsequent children) requires the same comprehensive evaluation as primary infertility 1

Lifestyle Optimization During Evaluation

Address modifiable factors that reduce fertility:

• Complete smoking cessation 2, 4
• Eliminate alcohol consumption 2, 4
• Reduce caffeine to <5 cups per day 4
• Discontinue recreational drug use 4
• Optimize BMI—both underweight and obesity reduce fertility rates 1, 4
• Avoid commercial vaginal lubricants (most reduce fertility) 1, 4
• Recommend vaginal intercourse every 1-2 days beginning soon after menstrual period ends 2, 4