When to See a Specialist About Secondary Infertility

Most patients with secondary infertility wait longer than they should before seeking evaluation. The reason is reasonable; the first pregnancy happened, so most patients assume the second one will eventually happen too. This article explains the medical recommendations and the reasoning behind them.

The basic timelines

These are the same timelines that apply to primary (first-pregnancy) infertility, and they apply to secondary infertility too.[¹]

The reason the timeline is shorter for older patients is that ovarian reserve declines steadily with age. Each month of trying after age 35 has less yield than a month at 30, and the window for treatment options narrows over time.

‍Shorter timelines apply when there is a known reason for concern

Evaluation should begin earlier, sometimes immediately, if any of the following apply:

• Irregular cycles: cycle length under 24 days or over 35 days
• A history of miscarriage: at any stage or age
• A previous Caesarean delivery: with persistent post-menstrual bleeding or known scar defect
• Painful periods: that have worsened since the first pregnancy (possible endometriosis or adenomyosis)
• Known PMOS: Polyendocrine Metabolic Ovarian Syndrome diagnosis (formerly PCOS)
• A male partner with a known fertility issue: previous abnormal semen analysis, varicocele, exposure to chemotherapy, etc.
• Maternal medical conditions that may affect fertility: thyroid disease, autoimmune conditions, recent significant weight change
• A previous fertility treatment: the first pregnancy involved IVF, IUI, or ovulation induction

Earlier evaluation in any of these scenarios is not pessimism, it is the recognition that a problem may already be identifiable.

What the first appointment involves

The initial fertility consultation is a conversation, not a procedure. It typically covers:

• A complete medical and reproductive history for both partners
• A review of the first pregnancy and delivery
• A physical examination if appropriate
• A plan for the next two to three weeks of testing

Testing is usually scheduled around the menstrual cycle and may include bloodwork on cycle days 2 to 4, transvaginal ultrasound to assess ovarian reserve and uterine cavity, a hysterosalpingogram or saline sonohysterogram to check fallopian tubes, and a semen analysis for the male partner.

A complete workup typically takes one to two cycles to complete.

What it costs and how OHIP applies

In Ontario:

• The initial fertility consultation is covered by OHIP: when seen by an Ontario reproductive endocrinologist
• Bloodwork and ultrasounds: for fertility evaluation are typically OHIP-covered
• Hysterosalpingogram: is OHIP-covered
• Semen analysis: is typically OHIP-covered as part of a fertility evaluation
• AMH testing: is not currently OHIP-covered and may have an out-of-pocket cost

For patients who proceed to treatment, the Ontario Fertility Program funds one IVF cycle for eligible patients, regardless of whether they have a previous child.[²]

‍What waiting too long costs

The most common consequence of waiting too long is the loss of treatment options. Specifically:

• Egg quality and ovarian reserve continue to decline during the months a patient waits. Tests that would have shown normal-for-age reserve at 36 may show diminished reserve at 38.
• The clinical picture narrows. Earlier evaluation often allows for less intensive treatment (timed intercourse, IUI, ovulation induction) before more intensive treatment (IVF) becomes necessary.
• The window for OFP-funded IVF closes at 43. Eligibility cuts off at age 43; women who wait past 42 may find they need treatment but can no longer access funding.[²]

None of this is meant to alarm. It is meant to underline that the cost of waiting is real, and the cost of evaluating earlier, when in doubt, is essentially zero in Ontario.

Frequently asked questions

Can I book a fertility consultation without my partner?

Yes. Many patients book the initial consultation alone, particularly when the male partner has a flexible schedule or lives elsewhere. The semen analysis can be scheduled separately.

What if my family doctor says to keep trying?

A family physician may reasonably suggest continuing to try if the timelines above have not been reached. If they have been reached, you can self-refer to a fertility specialist at Pollin, regardless of your family doctor's recommendation.

Do I have to do IVF if I see a fertility specialist?

No. A fertility consultation is a conversation about what is happening. Many patients leave a consultation with a less intensive plan; timed intercourse, monitoring, or ovulation induction, and never require IVF.

‍Will the consultation tell me whether I can have another child?

The consultation and workup will tell you what the most likely contributors are, what treatment options are realistic, and what the chances of success are. Honest counselling is part of a well-run fertility consultation.

‍References

1. Liu K, Case A. *Advanced reproductive age and fertility: SOGC clinical practice guideline.* J Obstet Gynaecol Can. 2017.

2. Ontario Ministry of Health. *Ontario Fertility Program: eligibility and patient information.* Government of Ontario, 2023.

This article is for educational purposes and does not replace individual medical advice.

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