What are the next steps for a woman over 35 who is not pregnant after 3 months of timed intercourse?

Immediate Infertility Evaluation Is Warranted After 3 Months in Women Over 35

For women over 35 who have not conceived after 3 months of timed intercourse, you should initiate a comprehensive infertility evaluation now rather than waiting longer, as guidelines recommend expedited assessment after 6 months for this age group—and 3 months of unsuccessful attempts justifies early intervention given age-related fertility decline. 1, 2

Why Earlier Evaluation Is Critical

• Women over 35 experience accelerated fertility decline, with fecundity decreasing more rapidly after age 37, making time-sensitive evaluation essential 3
• Standard infertility definitions (12 months for women under 35) do not apply here—the threshold is 6 months for women over 35, and evaluation can begin even earlier if clinically indicated 1, 4
• At 3 months without conception, you are justified in starting the workup immediately rather than waiting another 3 months, as each month of delay reduces pregnancy success rates in this age group 3

Initial Evaluation Components

For the Female Partner

Reproductive and Medical History 1:

• Menstrual cycle characteristics (length, regularity, dysmenorrhea onset/severity)
• Coital frequency and timing relative to ovulation
• Prior pregnancies, outcomes, and complications
• History of pelvic inflammatory disease, sexually transmitted infections, or ectopic pregnancy
• Previous pelvic/abdominal surgeries
• Thyroid disorders, hirsutism, galactorrhea, or other endocrine symptoms
• Current medications and family reproductive history

Physical Examination 1:

• Height, weight, and BMI calculation
• Thyroid examination
• Breast examination for galactorrhea
• Pelvic examination to assess uterine size, adnexal masses, and anatomic abnormalities

Laboratory and Imaging Studies 1, 5, 6:

• Cycle day 21 serum progesterone to document ovulation
• Ovarian reserve testing (particularly important over age 35)
• Thyroid function tests if symptoms present
• Hysterosalpingography or transvaginal ultrasound to evaluate uterine cavity and tubal patency (if no risk factors for tubal disease)
• Consider hysteroscopy or laparoscopy if history of endometriosis, pelvic infections, or ectopic pregnancy 6

For the Male Partner

Both partners should be evaluated simultaneously 1, 2:

• Obtain reproductive history including prior fertility, sexual function, childhood illnesses, systemic diseases, surgeries, sexually transmitted infections, and gonadal toxin exposures 1
• Order two semen analyses performed at least one month apart, with 2-3 days of abstinence before collection 1
• Physical examination focusing on genital anatomy, testicular size/consistency, presence of varicocele, and secondary sex characteristics 1

Common Pitfalls to Avoid

• Do not wait the full 6 months if the patient is already at 3 months—earlier evaluation is justified and recommended 1, 4
• Do not evaluate only the female partner—male factor contributes to 26-50% of infertility cases and should be assessed from the outset 1, 2, 4
• Do not assume ovulation is occurring based on regular menses alone—confirm with cycle day 21 progesterone testing 6
• Do not delay imaging if risk factors for tubal disease exist (prior pelvic infection, endometriosis, ectopic pregnancy) 6

Treatment Considerations Based on Findings

If Anovulation Is Identified

• Clomiphene citrate 50 mg daily for 5 days starting on cycle day 5 is first-line treatment for ovulatory dysfunction 7, 6
• If no ovulation occurs after the first course, increase to 100 mg daily for 5 days 7
• Treatment beyond 6 total cycles (including 3 ovulatory cycles) is not recommended 7
• However, clomiphene appears inefficient in women over 40, with very low success rates 8

If Unexplained Infertility Is Diagnosed

• For women aged 40-41, consider a short trial of gonadotropins with intrauterine insemination, then quickly proceed to IVF if unsuccessful 8
• For women over 41, IVF should be the primary treatment option given delivery rates with gonadotropins/IUI are less than 5% 8
• IVF is more efficient than traditional approaches in this age group, though absolute success rates decline with each year over 40 8

If Male Factor Is Identified

• Treatment options include gonadotropin therapy, intrauterine insemination, or in vitro fertilization depending on severity 6
• Referral to a male reproductive medicine specialist is appropriate 4

Age-Specific Urgency

The key distinction for women over 35 is that time is the enemy—ovarian reserve declines irreversibly, and pregnancy loss rates increase 3. While younger women can reasonably wait 12 months before evaluation, women over 35 require expedited assessment at 6 months, and women over 40 warrant immediate evaluation and treatment 1, 4, 3. At 3 months without conception, you are well within the window to begin this workup now.