Trying for a Year: A Step-by-Step Roadmap to a Fertility Workup

You've been trying for a year. Maybe a little longer. The home pregnancy tests keep coming up negative, well-meaning relatives have started asking pointed questions, and the next step feels both obvious and impossible to start. This guide walks through exactly what to do — in order — from the moment you decide it is time to talk to a doctor through to the diagnostic results that will shape your treatment plan.

The roadmap below applies in both Canada and the United States. We flag the differences as we go, including provincial fertility programs in Canada and how to avoid wasting months on the wrong workup in either country.

The 12-Month Rule (and When It Doesn't Apply)

The American Society for Reproductive Medicine (ASRM) and the Canadian Fertility and Andrology Society (CFAS) both define infertility as the inability to conceive after 12 months of regular, unprotected intercourse — but with important age-based exceptions:

• Under 35: Seek evaluation after 12 months of trying.
• 35 to 39: Seek evaluation after 6 months of trying.
• 40 and over: Seek evaluation immediately — do not wait six months.
• Known risk factors (irregular cycles, prior pelvic surgery, endometriosis, known male factor, prior chemotherapy, recurrent pregnancy loss): seek evaluation right away regardless of age.

The reason for the age tiers is straightforward biology: egg quantity and quality decline measurably from the mid-30s onward, and the success rate of every fertility intervention drops as well. Waiting an extra six months at 38 is not the same as waiting an extra six months at 28.

Roughly 1 in 6 Canadian couples experience infertility according to Health Canada, and the US Centers for Disease Control and Prevention (CDC) estimates about 1 in 8 US couples of reproductive age are affected. You are not unusual, and you are not alone.

Step 1: Track Before You Book

Before you call your family doctor or primary care physician, spend two to four weeks gathering data. This single step often shortens your workup by a full cycle:

• Cycle dates for the last three to six months — first day of period to first day of next period.
• Ovulation predictor kit (OPK) results for at least one full cycle. Note the day of the LH surge.
• Intercourse timing relative to the suspected ovulation window.
• Any symptoms that might matter: heavy or painful periods, mid-cycle spotting, pelvic pain, breast changes, weight changes, hair growth changes.
• Medication and supplement list for both partners, including over-the-counter supplements and any cannabis or alcohol use.
• Prior pregnancies, miscarriages, or surgeries for both partners.

Bring this on paper or in a phone note. A GP who can see actual cycle data in front of them will write a different (and better) referral than one who has to take your word for "my cycles are kind of regular, I think."

Step 2: The GP Visit and the Referral

In both Canada and the US, the first formal step is usually a primary care visit. The goal of this appointment is not to be diagnosed — it is to walk out with lab requisitions and a referral to a reproductive endocrinologist (REI) or, in some Canadian provinces, directly to a fertility clinic.

Ask the GP for:

• Cycle day 3 bloodwork: FSH (follicle-stimulating hormone), LH (luteinizing hormone), estradiol, and AMH (anti-Müllerian hormone). AMH can be drawn any cycle day.
• Thyroid and prolactin: TSH and prolactin, drawn any cycle day.
• Hysterosalpingogram (HSG): an imaging test of the uterus and fallopian tubes, scheduled between cycle days 6 and 12 (after your period ends, before ovulation).
• Semen analysis for the male partner, if applicable, with at least 2–5 days of abstinence beforehand.
• Referral to a fertility clinic or REI, sent the same day rather than "after we see how the labs come back."

The referral matters because clinic wait times in many Canadian provinces and busy US metro areas can run 2–4 months. If you wait for labs first, you add that wait on top of the clinic wait.

Once you've started the diagnostic workup, use the Fertility Link Navigator to see your provincial program eligibility and matched clinics — it takes 2 minutes.

Step 3: Understanding the Tests

A quick translation of what each test actually tells you:

• Day 3 FSH and estradiol estimate ovarian reserve. A high FSH on day 3 suggests the ovaries are working harder to recruit a follicle.
• AMH also estimates ovarian reserve and is more stable across the cycle. It does not predict whether you can get pregnant naturally — it predicts how your ovaries are likely to respond to fertility medications.
• TSH and prolactin screen for thyroid dysfunction and pituitary issues that can disrupt ovulation. Both are easy to treat if abnormal.
• HSG checks tubal patency — whether your fallopian tubes are open. A radiologist injects contrast dye through the cervix and watches it travel through the uterus and out the tubes on X-ray. It is uncomfortable, often crampy, and usually over in under 15 minutes. Take ibuprofen an hour beforehand. A blocked tube is a major finding because sperm and egg meet in the tube.
• Semen analysis measures volume, concentration, motility, and morphology. About 40–50% of infertility cases involve a male factor, alone or in combination with a female factor, so skipping this test is one of the most common ways couples lose months.

Step 4: Both Partners, Same Time

The single biggest avoidable delay in fertility workups is sequential testing — finishing the female partner's workup first, then starting the male partner's. Get both workups going in parallel from week one. A normal semen analysis is reassuring and cheap. An abnormal one changes the entire treatment plan and is worth knowing on day one rather than day ninety.

Step 5: Provincial Programs and the Ontario 2-Year Tip

If you are in Canada, the next step after the workup depends heavily on which province you live in. The major publicly funded programs include:

• Ontario Fertility Program (OFP): funds one IVF cycle per eligible patient per lifetime, plus unlimited monitored IUI and fertility preservation in certain cases.
• British Columbia BC Fertility Program: provincial funding for IVF cycles for eligible residents, with rollout details published by the Ministry of Health.
• Newfoundland and Labrador Fertility Subsidy: up to $20,000 in subsidy for eligible IVF treatment, announced in March 2025.
• Quebec: publicly funded IVF program for eligible residents under defined age and clinical criteria.
• Saskatchewan Fertility Treatment Tax Credit (FTTC): refundable tax credit on eligible fertility treatment costs.

A practical Ontario tip: OFP clinic waitlists historically run long, and many couples are told the wait can stretch toward two years. If you are 35 or older and you suspect you will need OFP-funded IVF, ask for the OFP referral the same day as your initial fertility clinic consult — not after a round of IUI. Time on the OFP waitlist passes whether you are doing other treatment or not.

For a side-by-side comparison of all provincial programs, see The Fertility Link provinces page.

Step 6: When to Skip IUI and Go Straight to IVF

IUI (intrauterine insemination) is cheaper per cycle and less invasive than IVF, but it is not always the right starting point. The clinical situations where most REIs will recommend skipping IUI and going directly to IVF include:

• Age 38 or older, because the per-cycle IUI success rate drops sharply and IVF is more efficient with limited egg supply.
• Severe male factor infertility, especially very low sperm count or motility where intracytoplasmic sperm injection (ICSI) is needed.
• Bilateral tubal disease identified on HSG, because IUI requires at least one open, functional tube.
• Recurrent pregnancy loss, where IVF with genetic testing may be more appropriate.
• Advanced endometriosis affecting tubal function or egg quality.

If any of these apply to you, ask your REI whether starting with IVF is the more time- and cost-effective choice.

Step 7: US-Specific Notes

In the United States, the workup itself looks nearly identical, but the financial path diverges. Some states have insurance mandates that cover diagnostic testing, IUI, and IVF — for example, the New York IVF insurance mandate covers eligible large-group plans. Others have no mandate at all, leaving the full cost out of pocket. Before booking the HSG or semen analysis, call your insurance and ask:

• Is fertility diagnostic testing covered, and if so, with what cost-sharing?
• Is treatment (IUI, IVF) covered, and what are the lifetime limits?
• Is there a required infertility diagnosis code or pre-authorization?

For employer-sponsored plans, the human resources benefits page often lists fertility coverage separately from general medical coverage. It is worth a careful read before you spend anything.

Step 8: Build Your Plan, Then Pick a Clinic

Once you have a diagnosis (or "unexplained" if everything looks normal), a sense of which treatment path makes sense (timed intercourse, IUI, or IVF), and a clear picture of provincial funding or US insurance coverage, you are ready to choose a clinic. Match success rates to your specific situation (age, diagnosis), not to overall headline numbers. Ask about embryologist staffing, lab quality control, and how the clinic handles add-ons that may or may not improve your odds.

Get Your Personalized Roadmap

Register at The Fertility Link to save your profile and get personalized clinic matches that account for your specific diagnosis and location. You can also browse provincial program details at /provinces and see your matched clinics at /matches once your profile is in.