Getting Pregnant After 40: What the Evidence Says

Plenty of people have babies in their 40s, and plenty need help to do it. The honest picture is that fertility is lower and falls faster after 40, so the advice changes from “keep trying” to “try and get evaluated at the same time”. This guide gives the numbers from a large study of people trying to conceive, explains what ACOG and ASRM recommend, and walks through the options.

Can you get pregnant naturally after 40?

Yes, though it usually takes longer. ACOG and ASRM say fertility declines gradually from about 32 and more rapidly after 37.¹ In PRESTO, a study of 2,962 couples in the United States and Canada who were trying without fertility treatment, women aged 40 to 45 had these results:²

Cumulative proportions are unadjusted; per-cycle ratios are adjusted fecundability ratios.² Only 38 women in the study were aged 40 to 45, so these figures come with wide uncertainty: the 12-cycle estimate’s 95% confidence interval ran from 30.7% to 80.2%.² They describe women with no known infertility who had just started trying, so they are a best case, not a forecast. Across all ages, the authors found a nearly linear decline in fecundability with increasing female age, and the association was stronger among women who had never been pregnant.²

When should you see a doctor after 40?

Now. ACOG and ASRM say that in women older than 40, more immediate evaluation and treatment are warranted.¹ ASRM’s evaluation guidance says the same: over 40, evaluation and treatment may start right away.³ You don’t need to try for 6 months first, and you can keep trying while tests are done.

The reason is time. ACOG and ASRM point to three factors that rise with age: the expected fertility decline, a higher rate of disorders that impair fertility, and a higher risk of pregnancy loss.¹ Finding a treatable issue, such as blocked tubes or a sperm problem, months earlier matters more at 41 than at 31.

What does the evaluation include?

The same core workup as at any age, done promptly: ovulation, ovarian reserve (AMH or an antral follicle count), thyroid, an ultrasound of the uterus, a test of whether the fallopian tubes are open and, at the same time, at least one semen analysis for a male partner.³ The AUA/ASRM guideline recommends assessing both partners concurrently.⁶ ASRM adds that ovarian reserve tests should support, not replace, counseling based on age and diagnosis, because female age is the single most important predictor of fertility.³ See when to see a fertility specialist.

What about AMH after 40?

Ovarian reserve declines with age, so AMH is usually lower in your 40s, and a low number can be alarming.⁴ Two points from the evidence help:

• It doesn’t predict natural conception. In a JAMA study of 750 women aged 30 to 44, low AMH did not reduce the chance of conceiving within 6 or 12 cycles.⁵ ASRM says ovarian reserve tests should not be used as a fertility test.⁴
• It shapes IVF, but should not block it. AMH predicts how many eggs IVF stimulation will retrieve. ASRM says even extremely low AMH should be used to counsel, not to refuse treatment; in national data on cycles with AMH below 0.16 ng/mL, the live birth rate was 9.5% per cycle started.⁴

AMH also did not predict pregnancy after ovarian stimulation with IUI in a trial of 900 women with unexplained infertility.⁴ Age is still the stronger predictor of success.⁴ See low AMH.

Treatment options after 40

• Ovulation induction with timed sex or IUI. Often a first step if tubes are open and sperm is normal; see IUI vs IVF.
• IVF with your own eggs. Success falls with age, so ask the clinic for its own live-birth rates for your age group and how many cycles it recommends planning for. For budgets, see IVF cost.
• IVF with donor eggs. An option many clinics discuss in the 40s. ASRM’s 2023 definition of infertility explicitly includes needing donor eggs or embryos to achieve a pregnancy.⁷

Ask any clinic for its numbers by age, with own and donor eggs, so you can compare like with like. Ask too how many patients each figure is based on and whether it counts live births per cycle started or per transfer, because the same clinic’s numbers can look very different depending on which is used, as ASRM’s own example shows (9.5% per cycle start versus 20.5% per transfer in very low AMH cycles).⁴

A realistic plan after 40

1. Book the evaluation now and keep trying while you wait for it.¹
2. Get the semen analysis done first, because it is the fastest test and can change the plan.⁶
3. Agree a plan with your clinician for each step: how many cycles of ovulation induction or IUI, if any, and when to move to IVF.
4. Ask about donor eggs early, even if you plan to start with your own, so you understand the option and its timeline.
5. Review after each step. If a step fails, the plan should change, not repeat indefinitely.

The ASRM evaluation guidance asks clinicians to keep the workup systematic and quick, starting with the least invasive tests for the most common causes.³ That is especially relevant after 40, when time is the scarcest resource.

Don’t forget the other partner

In PRESTO, male age had little effect on fecundability after accounting for female age, though there were few men over 45.² The AUA/ASRM guideline asks clinicians to tell couples that a father aged 40 or older carries an increased risk of some adverse health outcomes for children.⁶ A semen analysis is quick and cheap; see semen analysis results.

Looking after yourself

Trying in your 40s can come with time pressure from every direction. It helps to set a plan with your clinician (how many cycles of each step, and when to change course), and to look after your mental health along the way: see the Support section. If you are 35 to 39, read getting pregnant after 35; the Investigate hub covers every test.