A descriptive analysis of a fertility services waitlist in Eastern Canada.

Hannah M. Murphy: Writing – review & editing, Writing – original draft, Validation, Methodology, Data curation. Bailey P.S. Cox: Writing – review & editing, Formal analysis, Data curation. Heather M. Manning: Writing – review & editing, Methodology, Investigation, Formal analysis, Conceptualization. Zohreh Zeidy: Writing – review & editing, Investigation, Formal analysis. Sarah Benson: Writing – review & editing, Formal analysis, Data curation. John D. Cullen: Writing – review & editing, Methodology, Formal analysis, Conceptualization. Deanna Murphy: Writing – review & editing, Supervision, Methodology, Investigation, Conceptualization. Sean Murphy: Writing – review & editing, Supervision, Methodology, Investigation, Conceptualization. Sarah Healey: Writing – review & editing, Supervision, Methodology, Investigation, Conceptualization. Laurie Twells: Writing – review & editing, Supervision, Methodology, Investigation, Formal analysis, Conceptualization. Katie P. Wadden: Writing – review & editing, Supervision, Methodology, Investigation, Data curation, Conceptualization.

This study is a descriptive, cross-sectional characterization of patients seeking care for infertility at the NLFS. All referrals to the clinic received between April 2023 and September 2023 were assessed for inclusion. The NL Health Research Ethics Board (HREB) provided ethical approval for this study (Reference Number: 20230825). Referred patients were assigned a de-identified study number. A master list was created linking patient names; however, this is only accessible to clinic staff and the lead researchers. Deidentified data, including sex based on patient records, age, first 3 digits of postal code, and reason for referral, were extracted from the list of referrals. Furthermore, whether a partner was referred and, if indicated, the partner’s sex and age were also extracted. The inclusion criteria for this study are 18 years old or older and being referred to NLFS by a health professional. NLFS provides a wide range of reproductive endocrinology and infertility services. Reasons for referral were grouped into the following categories: (1) Infertility (including inability to conceive with regular intercourse, abnormal seminal analysis, and ovarian insufficiency), (2) oocyte or sperm cryopreservation, (3) donor sperm insemination, (4) recurrent pregnancy loss (5) preconception counselling, or (6) other. In the case of overlap in reasons for referral, the primarily stated concern based on the researcher’s discretion was used for grouping. As maternal age has been identified as the most important determinant of fertility, 7 the age of the referred female patients or partners was extracted. Furthermore, the SOGC Clinical Practice Guidelines recommend informing prospective parents that fertility begins to decline significantly after the age of 32 years and that expedited evaluation should be initiated in females 35 years or above. 7 For this reason, extracted ages were grouped into categories: under the age of 32 years, 32–34 years old, and 35 years or older. Previously, healthcare in NL was delivered by 4 distinct health authorities by region: Eastern, Central, Western, and Labrador-Grenfell. In 2023, these were combined into the NL Health Services, which includes 5 regional zones: Eastern-Urban, Eastern-Rural, Central, Western, and Labrador-Grenfell. 18 The NLFS is in the Eastern-Urban zone. See Figure 1 for a map of boundaries of these zones. 18 Figure 1 Regional zones boundaries. Image owned by NL Health Services and reprinted with permission. Available from https://nlhealthservices.ca/wp-content/uploads/2023/07/NLHS-Regional-Map.pdf . Murphy. A descriptive analysis of a fertility services waitlist in Eastern Canada. AJOG Glob Rep 2025. Figure 1 Regional zones boundaries. Image owned by NL Health Services and reprinted with permission. Available from https://nlhealthservices.ca/wp-content/uploads/2023/07/NLHS-Regional-Map.pdf . Murphy. A descriptive analysis of a fertility services waitlist in Eastern Canada. AJOG Glob Rep 2025. To investigate infertility referral patterns across the province’s geography, the first 3 digits of postal codes were extracted from referral documents and assigned to their associated NL Health Services zone. In cases where one postal code region included areas of more than one health zone, the zone that made up the widest proportion of the region was assigned. To account for population differences when describing referral patterns across the province, live birth rates were retrieved for each of the 4 previous health authorities (Eastern, Central, Western, and Labrador-Grenfell). A 5-year average annual live birth rate was calculated for each region, using data from 2017-2021. Due to the exploratory nature of this study, a detailed descriptive analysis of variables was completed. The reasons for referral were summarized, with the frequency and percentage of referrals for each reason calculated. As this study aimed to characterize patients referred to NLFS for infertility, only patients with this reason for referral were included in further analyses of female age and geographic referral patterns. To describe referral patterns across the province, frequencies and percentages for the NL Health Services geographical zones from which patients were referred were calculated. To account for population differences, relative referral rates for each region were calculated with the number of referrals for infertility received during our study period as the numerator and number of female of childbearing age (14–49 years of age) as the denominator. Due to availability of data, live birth rates from the previous NL health authority regions were used for this calculation and accordingly, referral counts for Eastern-Urban and Eastern-Rural zones were combined into “Eastern” region. A Chi-square Goodness-of-Fit test was conducted to compare observed referrals to the expected referrals based on live births in each geographic zone. The effect size was measured using פ (Fei). 19 The distribution of female age was investigated, and the mean and standard deviation were determined. The age of female patients was also compared between NL Health Services zones. Due to large differences in referral numbers for each zone, for this analysis, all zones besides Eastern-Urban were combined into one group. A t-test was used to compare the age of female patients referred for infertility between the Eastern-Urban zone and all other zones. Levene’s test was used to verify the homogeneity of variance for these samples.

This manuscript does not contain personal medical information about an identifiable living individual and thus, patient explicit consent is not required.

Over the 6-month period of April 1st to September 30th, 2023, 319 patients were referred to NLFS. One patient was excluded due to being under the age of 18 and another due to referral information which was not able to be accessed from records. Reason for referral was extracted for 317 patients. Most of the referrals were for infertility (n=221, 70%). Other reasons for referral included recurrent pregnancy loss (n=27, 9%), oocyte or sperm cryopreservation (n=24, 8%), preconception counselling (n=21, 7%), donor sperm insemination (n=16, 5%), tubal ligation reversal (n=6, 2%), and unspecified (n=2, 1%). Patients referred for infertility were further analyzed to describe referral patterns across the NL Health Services geographical zones and age of female patients referred. The Eastern-Urban zone had the highest number of referrals for infertility (n=145), comprising 66% of the sample. 14% of referrals were for patients in the Eastern-Rural zone (n=32), 9% for patients in the Central zone (n=19), 6% for patients in the Western Health zone (n=14), and 2% for patients in the Labrador-Grenfell Health Zone (n=5). Three percent of referrals (n=6) were from out of province, had an invalid postal code, or did not specify a postal code. The number from referrals from the Eastern region more than doubled any other zone in the province after accounting for population differences using live birth rates. The Eastern region referral rate was 72 referrals for infertility received during the study period, for every 1000 annual live births. For referral rates for Central, Western, and Labrador-Grenfell were 33, 30, and 14 referrals for infertility for every 1000 annual live births, respectively. A Chi-square test evaluating the distribution of referrals based on live birth rates was statistically significant with a small effect size, x 2 =28.97, P ≤.001; פ=0.10, 95% CI [0.07, 1.00]. There were more referrals from the Eastern region of the province (std. resid=5.30), and less referrals in Central, Western, and Labrador-Grenfell (std resid=–2.44, –2.76, –2.84, respectively), than expected based on live birth rates. The age of female patients referred for infertility ranged from 20 to 49 years. Age was normally distributed, with skewness of 0.093 ( SE =0.17) and kurtosis of –0.092 ( SE =0.33), as assessed by Shapiro-Wilk's test (0.991), P =.228. The mean age was 33.09 years ( SD =5.03). Figure 2 depicts the distribution of the age of female patients. Figure 2 Distribution of age of female patients referred to the newfoundland and labrador fertility services for infertility. Murphy. A descriptive analysis of a fertility services waitlist in Eastern Canada. AJOG Glob Rep 2025. Figure 2 Distribution of age of female patients referred to the newfoundland and labrador fertility services for infertility. Murphy. A descriptive analysis of a fertility services waitlist in Eastern Canada. AJOG Glob Rep 2025. Approximately one-third (36%) of referrals included female patients under the age of 32 (n=79). Twenty percent included female patients between the ages of 32 and 34 (n=45). Finally, 40% included females 35 years or older (n=88), and 4% of referrals did not specify female age (n=9). There 207 referrals for infertility with health zone and female age data available in patient records. Sixty-seven percent of these referrals (n=138) were from the Eastern-Urban health zone and 33% (n=69) were from other health zones. Patients referred from the Eastern-Urban zone were older ( M =33.96, SD =4.9) than those referred from other health zones ( M =31.42, SD =4.9), t (205)=3.50, P ≤.001. Levene’s Test for Equality of Variances confirmed the homogeneity of variances between these groups ( F =0.148, P =.701). See Figure 3 for a bar graph of this comparison. Figure 3 Age of patients referred to newfoundland and labrador fertility services for infertility by geographical health zone. The average age of female patients referred to the Newfoundland and Labrador Fertility Services from the Eastern-Urban health zone and other health zones, which includes the Eastern-Rural, Central, Western, and Labrador-Grenfell zones; *2-sided P value <.001. Murphy. A descriptive analysis of a fertility services waitlist in Eastern Canada. AJOG Glob Rep 2025. Figure 3 Age of patients referred to newfoundland and labrador fertility services for infertility by geographical health zone. The average age of female patients referred to the Newfoundland and Labrador Fertility Services from the Eastern-Urban health zone and other health zones, which includes the Eastern-Rural, Central, Western, and Labrador-Grenfell zones; *2-sided P value <.001. Murphy. A descriptive analysis of a fertility services waitlist in Eastern Canada. AJOG Glob Rep 2025.

Average referral age underscores the need for timely infertility interventions in Eastern Canada.

Most referrals to the NLFS were for infertility. A disproportionately high number of referrals were for patients from the Eastern-Urban health zone, which suggests potential barriers to accessing fertility services from other regions of the province. More than half of the referred female patients are 32 years old or older, which emphasizes the need for prompt medical or community intervention. Patients referred from areas outside the Eastern-Urban zone were younger, which may reflect lifestyle differences between regions of the province.

The purpose of this study was to characterize the waitlist for fertility services in NL, Canada. It aimed to describe the demographics of patients seeking care for infertility. Over a 6-month period, the NLFS received 317 referrals that met the study’s inclusion criteria. The majority of referrals were for patients with a primary concern of infertility, with other common reasons for referral being recurrent pregnancy loss and oocyte or sperm cryopreservation. Most referrals for infertility, adjusted for population live births, were for patients residing in the province’s Eastern region of the province. The number of referrals for infertility from the Eastern region was higher than expected based on live birth rates, while the referral rates from Central, Western, and Labrador-Grenfell regions were all less than expected. In NL, the referral is for the primary patient who requested it, and thus, only information for one of the patients for the referred couple was provided. Interestingly, the patients who requested the referral were all females, thus indicating a social rather than biological finding. As a result, male participants were not included in the current analysis, despite the known contribution of both partners to infertility. In the present study, the average age of female patients referred for infertility was 33 years. Patients referred from other regions of the province were younger than those referred from the Eastern-Urban health zone. The highest number of referrals to the NLFS are from patients with infertility. Specifically, 70% or 221 referrals over 6 months were for infertility. Notably, an Australian study that investigated the management of infertility in primary care reported that only between 21.5% and 42.1% of visits to general practitioners resulted in referral to a specialist clinic. 20 Therefore, there may be a larger group of individuals in NL experiencing infertility who are managed by general practitioners or general obstetrics and gynecology services, who are not captured by this study. Interestingly, fewer than 1% of people in Newfoundland and Labrador seek fertility treatments, which warrants further investigation into referral pathways and access to services. 6 Other reasons for referral to the NLFS included recurrent pregnancy loss, oocyte or sperm cryopreservation, preconception counselling, donor sperm insemination, and tubal ligation reversal. It is important to note that patients with failure to conceive may also have other diagnoses, such as endometriosis, not indicated on the referral. The greatest number of referrals for infertility, adjusted for females of childbearing age, were for patients residing in the Eastern-Urban health zone. Specifically, the relative referral rate from the Eastern region was more than double that of any other zone. The second highest was Eastern-Rural, followed by Central, then Western, and with the lowest number of referrals from the Labrador-Grenfell zone. The referral rate in the Eastern region was higher than expected based on live birth rates, while the referral rates from all other regions were lower than expected. Several factors could explain this discrepancy, including access to a healthcare provider to provide a referral, lack of knowledge of available services, or referral to a general gynecologist in their region. Indeed, the percentage of the population with a regular health care provider was lowest in Labrador-Grenfell region. 13 Nonetheless, an Australian study reported lower odds of referral from a general practitioner to a fertility specialist when living in a remote location, 20 which suggests that there may be additional barriers to referral even when a provider is available. For instance, the NLFS is located within the Eastern-Urban zone, and travel time has been noted as a barrier to utilizing fertility services in other countries. 21 Nonetheless, NLFS offers virtual visits for individuals living geographically far away, which helps to mitigate this barrier. The average age of females referred to the NLFS for infertility was 33 years. This finding is in line with an investigation of patient experience at US fertility clinics between 2015 and 2018, which also reported an average female age of 33 years, 22 though this was data from the patients’ first visit to a clinic and not during the waiting period. Despite the possibility that patients referred to the NLFS may be older by their first visit to the clinic, 60% of the waiting population were 32 years of age or above, which represents a period where fecundability is declining. 7 Furthermore, 40% of referred female patients were 35 years old or above, where the risk of obstetrical and perinatal complications is increasing, and expedited assessment is recommended. 7 Given the advanced age of the waitlist population in NL, prompt intervention is important. Interestingly, the age of female patients referred to the NLFS from areas outside the Eastern-Urban zone were younger. Proposed reasons for delayed childbearing include a shift in social norms, increased education, and participation in the workforce. 23 Therefore, differences in these factors between urban and rural areas could explain the younger presentation of females to the NLFS in regions outside the Eastern-Urban health zone. Furthermore, given that modifiable factors, including obesity, diet, and smoking, can impact fertility status, 15 reports of poorer cardiometabolic health in rural Canadian populations may also contribute to younger presentations with infertility. 24 The current study was a cross-sectional characterization of the waitlist for fertility services in NL, Canada. To receive fertility services from a specialist at NLFS, a referral is sent on behalf of the patient(s) by a family physician, consultant physician, or nurse practitioner. The data extracted for the waitlist database included in this study is based on referral information only. Follow-up with the patient cohort would allow studies to report on the duration of the waiting period. The current study design limited the description to basic, unidentifiable variables from patient records. Future studies may aim to characterize modifiable lifestyle factors that can impact fertility, such as weight management and nutrition, 15 and should report on the population seeking fertility services in the other provinces and countries.

Infertility is defined by the World Health Organization (WHO) as the inability to achieve pregnancy after at least 12 months of regular, unprotected sexual intercourse. 1 It is estimated that 1 in every 6 people experiences infertility in their lifetime. 2 Common causes of infertility include blocked or damaged fallopian tubes, ovulatory dysfunction, or sperm abnormalities. 3 Infertility has a profound psychological burden on couples, including higher levels of stress and increased rates of anxiety and depression. 4 Furthermore, affected couples often dedicate large amounts of time and money to achieving fertility goals. 5 In Canada, waiting times for fertility services vary significantly between provinces. In the province of Newfoundland and Labrador (NL), a recent report on wait times estimated a range from immediate to 9 months based on triaging factors such as medical need. 6 The Society of Obstetricians and Gynecologists of Canada (SOGC) Clinical Practice Guidelines state that maternal age is the most important determinant of fertility. 7 Female aging is associated with fewer oocytes and anovulation. 3 , 8 Studies have reported a linear decline in achieving unassisted pregnancy, as well as a lower assisted reproductive technology success rate with increasing female age. 9 Despite this, delayed childbearing has become more common, with the percentage of live births in Canada with a maternal age of 35 years or greater increasing from 16% in 2000 to 26% in 2022. 10 Furthermore, patients may not recognize the need for referral and often wait multiple years before seeking medical attention. 11 Unfortunately, there is limited preconception data available to describe the age of couples seeking care for infertility in Canada. Given the trends towards delayed parenthood and reduced fecundity with age, timely access to interventions is critical to achieving optimal fertility outcomes. However, access to both primary and specialty healthcare services in Canada is an ongoing challenge, with the province of NL reporting a poor rank on timeliness metrics. 12 Disparities in access to care also exist across the province, for instance, with the percentage of individuals having a regular health provider being lower in northern regions. 13 The province has only one endocrinology and infertility services clinic, known as NL Fertility Services (NLFS). Located on the province’s eastern side, within its Eastern-Urban health zone, NLFS serves the entire population within a vast and rural geography. NLFS provides a wide range of services to the province, including counselling, fertility investigation, follicular tracking, ovulation induction, intrauterine insemination (including therapeutic donor insemination), sperm preservation, and tubal surgery. Coverage for the services varies; while some are insured under the provincial healthcare plan, others may be delivered at no cost to the client or require out-of-pocket payment. In Vitro Fertilization (IVF) is not currently offered in NL. 6 The extensive post-graduate medical education required to deliver these services is a barrier to providing specialized care at additional locations across the province. In Canada, family physicians are often the first point of contact for a patient's concerns regarding fertility. Given this, they play a key role in the assessment of infertility. 14 For example, family physicians may provide preconception counselling regarding lifestyle factors that can affect fertility, complete an initial history, physical exam, and investigations, such as blood tests to explore possible ovulation dysfunction, tubal damage or dysfunction, and male factors. Pharmacological treatments that may be available in a family physician's office, such as clomiphene citrate or the off-label use of insulin-lowering agents for women with polycystic ovarian syndrome. 14 Nonetheless, what is offered by family physicians varies based on several factors, such as training. However, there is an opportunity for the waiting period for specialist services to serve as a time to implement lifestyle interventions that may increase fertility markers and provide patients with much-needed informative resources. Research has proposed several modifiable factors that can impact fertility, including but not limited to weight management, nutrition, smoking, and environmental exposures. 15 For instance, in line with the SOGC recommendations of diet and exercise pre-pregnancy for females with obesity, 16 a recent review reported that various exercise techniques improved fertility outcomes for this population. 17 Importantly, demographic data characterizing the population seeking infertility services would be critical to begin to develop resources. To our knowledge, there are no studies reporting referral patterns across the province of NL. The primary goals of the current study are to 1) determine the proportion of patients referred to NLFS due to infertility, 2) describe other common reasons for referral to NLFS, 3) gain insight into infertility referral patterns across the province of NL, and 4) report the age of females seeking infertility care. The findings will provide essential information to help design interventions and resources for patients and primary care providers to use while waiting for specialist services.