Synopsis
Define delayed conception inclusively, recognise when investigation should begin, assess both partners in parallel, and direct people promptly to the right generalist or specialist pathway.
- NICE NG257 defines the practical investigation threshold by time trying: usually 12 months of regular unprotected vaginal intercourse, or 6 unsuccessful artificial-insemination cycles, when no cause is already suspected.
- Do not wait for a time threshold when the person trying to become pregnant is 36 or older, either partner has a known or suspected cause, or there is a relevant predisposing history.
- A miscarriage or ectopic pregnancy during the qualifying interval does not reset the clock; continue counting the original timeframe.
- Assess both partners concurrently where conception is attempted with partner sperm; a normal result in one person does not remove the need to assess the other.
- Regular vaginal intercourse every 2 to 3 days optimises the chance of conception; artificial insemination should be timed around ovulation.
- Over 80% of heterosexual couples in the general population conceive within 1 year when the woman is under 40 and intercourse is regular without contraception; about half of the remainder conceive in year 2.
- The opening assessment covers reproductive, sexual, medical, surgical, medicine, family, lifestyle and occupational history, followed by targeted examination and parallel semen and ovulation-focused testing.
- Offer evidence-based information and independent counselling before, during and after investigation or treatment, irrespective of outcome.
Key red flags
A positive pregnancy test with unilateral pelvic pain, shoulder-tip pain, bleeding, syncope, shock or peritoneal signs requires urgent assessment for ectopic pregnancy.
Sudden severe testicular pain, a high-riding testis or nausea is testicular torsion until excluded and needs immediate surgical assessment rather than a routine fertility referral.
A hard intratesticular lump, progressive unilateral enlargement or a persistent unexplained testicular abnormality needs urgent suspected-cancer evaluation.
New visual-field disturbance, severe headache, ophthalmoplegia, vomiting or other focal neurological change with menstrual disturbance can indicate a sellar mass and warrants urgent assessment.
Chemotherapy, pelvic radiotherapy, gonadectomy or another treatment likely to impair fertility should trigger an expedited preservation discussion before treatment whenever clinically possible.
Investigation priorities
Define duration, route to conception and risk factors in everyone contributing gametes.
Management branches
A person or couple is concerned about delayed conception.
- Establish who is trying to conceive, whose gametes are involved, the method and frequency of attempts, duration, pregnancy history and whether intercourse or insemination is difficult.
- Look immediately for age-related urgency, known reproductive disease, gonadotoxic treatment, acute pregnancy symptoms, testicular emergency and safeguarding concerns.
- Explain realistic population probabilities, advise intercourse every 2 to 3 days or insemination around ovulation, and agree when formal tests start.
The person trying to become pregnant is 36 or older, a cause is suspected, first-line tests are abnormal or treatment is likely to impair fertility.
- Send a concise referral with duration, pregnancy history, relevant operations and treatments, cycle details, semen results and tests already completed.
- Expedite fertility-preservation assessment before gonadotoxic treatment and coordinate with oncology or the treating specialty so referral does not delay essential care.
- Explain that NHS treatment recommendations and locally commissioned access are related but not identical, and offer independent counselling while decisions are made.