Women's Health Matters

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In July 2008, our guest expert in Le Club's Ask the Expert segment was Dr. Karen Glass, a specialist in gynecology and reproductive medicine at Women’s College Hospital and Sunnybrook Health Sciences Centre in Toronto.

Born in Toronto, Dr. Glass attended the Ontario Science Centre Science School.  She then took her undergraduate training at the University of Western Ontario, her medical training at the University of Ottawa and her postgraduate obstetrics and gynecology training at McMaster University. 

Dr. Glass' interest in laparoscopic and hysteroscopic surgery drew her to UCLA where she completed a two-year fellowship with a dual appointment in the divisions of Reproductive Endocrinology & Infertility and Urogynaecology. 

She returned to McMaster University in Hamilton as an Assistant Professor.  In 2002, she moved her practice to Women’s College Hospital and Sunnybrook Health Science Centre where she works at the CReATe IVF Program.

Dr. Glass currently sees patients with infertility, recurrent pregnancy loss and reproductive gynecologic concerns. Her area of special interest is fertility preservation in female cancer patients.

Here are Dr. Glass’s answers to your questions on infertility:

Q: I have had infertility issues. Doctors diagnosed me with positive ANA and concluded that was the cause of my miscarriages. However, my last pregnancy was ectopic and had to be terminated. What treatment options are available for the ANA issue? As well, what are the reasons for ectopic pregnancies, and can they happen more than once?

A: There are two different issues here. The first one is the recurrent miscarriages. This is an extremely complex issue that can be caused by many different problems including: genetic, infectious, autoimmune, abnormal uterine shape, thrombophilic (blood clotting) and hormonal ones. ANA is one of the autoimmune issues. The treatment of ANA depends on the level and type of the blood result. Options include low-dose aspirin, dexamethasone, heparin and fragmin. The decision should be made by a physician with expertise in infertility and recurrent miscarriages.

The second problem is the recent ectopic pregnancy. The cause of ectopic pregnancies is often unknown, but the risk factors include: scar tissue secondary to infections such as Chlamydia and pelvic inflammatory disease (PID), previous pelvic surgery, endometriosis, use of an IUD and smoking.

Most research suggests that the recurrence risk after one ectopic pregnancy is about 15 percent.


Q: I am 40 years old. I have had one baby who is 15 months old. I want to get pregnant again. I have multiple uterine fibroids. The largest is almost 12 cm. My concern is that if I remove them it could cause further scar tissue and lessen my already low fertility rate. However, if I get pregnant because of the fibroids I may have an extremely difficult pregnancy. We have been trying for almost 6 months now. What would you recommend I do in this situation?

A: I recommend that you seek an expert infertility opinion. There is much controversy about fibroids and fertility. The answer to your questions depends on the location of your fibroid in the uterus, the time it took you to conceive the last time, the size of your fibroid during your last pregnancy and your ovarian reserve. After all of these questions are answered a relevant discussion can ensue with your physician.


I am 33 and planning to have a baby when I am 37. My partner is nine years older than me. We are in good health with no major identified health problem. Are we planning right? 

A: Fertility starts to decline at 28 years old. Initially there is a slow decline.  At 35 years old the decline increases and is rapid after 40. The younger you are when you conceive the less chance there is to have a baby with Down’s Syndrome. 

It is impossible to know if you will be fertile at 37 years old. There are a few tests that can help to predict future fertility such as hormonal blood tests, antral follicle count on ultrasound, regular menstrual periods, no risk factors for tubal disease and normal semen analysis (sperm count).  However, normal tests now do not guarantee future fertility. In my opinion, the sooner you start to try to conceive, the better.


Q: To what extent can the most severe endometriosis and adenomyosis affect fertility? Aside from laser removal, is there any treatment or prevention for endometriosis? Is there any treatment for adenomyosis? Are there any alternative medical techniques that can help with either of these conditions? Is there a known cause for adenomyosis? Is in vitro fertilization (IVF) a viable option for conception in a confirmed case of severe adenomyosis?

A: Endometriosis is a risk factor for infertility, as it causes scarring in and around the fallopian tubes.  Adenomyosis is a form of endometriosis where cells that are similar to the lining or endometrium of the uterus are located in the muscle layer of the uterine wall. In women with severe endometriosis there is usually tubal damage that requires IVF. 

In Ontario, OHIP covers IVF treatment if both fallopian tubes are blocked. There are many medical treatments for endometriosis and adenomyosis such as Depo Lupron and Danazol. Unfortunately, all of the medical treatments cause periods to stop by stopping ovulation.  If you are not ovulating you cannot get pregnant.

Thus, treatment with these medications will help the symptoms of the disease but will delay the time until the woman can try to get pregnant. IVF is a viable option for adenomyosis and endometriosis; however, the success rates in patients with MRI proven adenomyosis was lower than in patients with a normal uterus in published research. The cause of endometriosis and adenomyosis has been researched for decades. There are various theories but no definite answers.


Q: Hello. I am 35 years old and my husband and I have been trying to conceive for about seven months now. I have been taking my temperature every morning and also checking my cervix to see when I am most fertile. We still have had no success so my husband has gone to the doctor to have a sperm count done. I know that about 50 percent of couples conceive within the first year, but I guess my husband and I did not think it would take this long. Do you have any suggestions?

A: At 35, you have a 15 to 20 percent chance of pregnancy each month.  Infertility is defined as more than one year of trying without success.  Mathematically that means that about 80 percent of couples should be pregnant after one year of trying. The remaining 20 percent have infertility. 

If you do not have success in the next few cycles then you should seek a referral to an infertility clinic where a full investigation can be performed. While you are waiting, you can try an ovulation kit which you can purchase at any drug store. This kit has a stick that you urinate on (similar to a home pregnancy test).

The test sticks will indicate the correct time of your cycle to have intercourse when you are ovulating. Unfortunately, they are somewhat costly, at about $60 to $70 for one kit with five test sticks. Apparently, you can buy them on the Internet for a much reduced cost.


I have had two or possibly three miscarriages in the last two years.  I had the first miscarriage at about six weeks, when I was 17.  The cause of loss was undetermined. Then about a year later I had another pregnancy that I lost at 15 weeks. They said the baby did not have a stomach and the intestines were hanging out. The doctors did a chromosome test and it came back fine. What could cause that? Is it something I did? About three months later when I got my period back I had clots and they said it was most likely another miscarriage, but I didn’t even know I was pregnant. Is it normal to have three miscarriages and what are the chances of it happening again?

A: More than or equal to three miscarriages (1% of couples trying) is considered abnormal and warrants a consultation to a fertility specialist familiar with recurrent pregnancy loss. Miscarriages are more common the older the mother becomes. It sounds like yours all occurred at a very young age when they are less likely. You described your second miscarriage with an abnormal baby who likely had a birth defect called gastroschisis which is a hole in the abdominal wall where the intestines can hang outside the body.  This is usually a random event that does not recur.

There was nothing that you did to cause this. The various possible causes of recurrent pregnancy loss are listed in the first question. If you are still actively trying to have a baby I recommend help, as mentioned above, as you have a 40 to 45 percent chance of having another miscarriage.


Q: I'm 48. Can I still get pregnant if I'm perimenopausal?

A: Please see the answer to the third question above. The oldest patient that I’ve ever been able to help conceive with her own eggs was 45. If you are perimenopausal and 48 years old you will not be able to conceive with your own eggs, but you can with either a known or an anonymous egg donor.


Q: I turned 41 a few months ago. I am currently in a long term relationship with a man who most emphatically does NOT want children. This didn't bother me as much when I was in my early 30s, but it is starting to now. Have I given up my "fertile years" to be with him? I can't help resenting the situation a little (even though he was always honest with me) and wondering if I have made a mistake. Should I stay with him, and try to be content, childless? Or should I leave the relationship and try to have a child without him? What are my chances of getting pregnant (for the first time) at my age? I am healthy, have no perimenopausal symptoms, and have regular periods. My mother had a child at age 46, if that makes any difference, genetically.

A: I’m sorry to hear your emotional struggle! We have many patients who do conceive at 41. Obviously, you have a social decision to make about how to proceed. Many fertility clinics have social workers, counselors and self help groups that can assist you with this quandary. In general, it is more difficult to conceive at 41 years old and miscarriages are common (approximately 50 percent of pregnancies).  There are some simple blood and ultrasound tests that will help to answer your questions about your ovarian reserve better than population-based statistics will. If you see a fertility specialist you can have an individualized answer to the questions, and then make an educated decision. Please see the answers to the third and seventh questions above for more information. 

Q: Do you think that someday there might be a “cure” for menopause that would restore a woman's fertility?

A: This is a very interesting topic.  There is much research on how to make eggs that are damaged by age into better quality, more youthful eggs.  Currently, there is not a definitive answer. Most people who are afraid of running out of time are more interested in the option to freeze their eggs (in essence freezing their age) for future use. Women are born with all of the eggs that they need, which are slowly but surely depleted or die, whereas men are continually making more sperm.  It is because of this that I feel that it will be a long time before we can “cure” menopause.


Q: Can medications such as Depo Provera and birth control pills cause infertility problems?

A: Birth control pills, patches and rings do not cause infertility problems.  Depo Provera has a somewhat lasting effect. Thus it will take three to six months after the last injection for regular periods to return. Once the cycles have returned, then the contraceptive effect is gone and baseline fertility has returned.


Q: For how many years without success should a couple continue to try to conceive? My husband and I have been trying to have a baby for over eight years.  We have tried IUI and IVF and have not been successful.  What are our chances of conceiving on our own at this point?  I am 35 years old.

A: Research shows that after three fresh IVF cycles that the chance of a fourth cycle being successful is less. Thirty-five is a grey-zone age for fertility.  But you did not mention any of the other factors regarding infertility such as tubal disease, endometriosis, ovarian reserve issues and any male factors. 

Also, there are various tests that can be done to look for causes of implantation failure. You didn’t mention if any of these tests are abnormal.  The final answer to your question is that you do have options.  Without knowing the details of your fertility challenges, I cannot definitively answer your question.


Q: How can I find out – in an affordable way – if I am fertile or not, so that I can stop using pregnancy prevention methods?

A: There are no definitive “over the counter” methods to assess your fertility.  As you have likely noticed from my answers to many of the questions above, age is extremely important. You’ve not mentioned your age in this question.  If you are less than 42 years old with regular periods and no previous tubal infections such as PID (pelvic inflammatory disease), and no previous abdominal surgery, then you are likely fertile and require contraception (pregnancy prevention methods). 

I’m sure that your family physician would be happy to discuss this with you.  There are many birth control clinics that can also help you determine which method of pregnancy prevention is most suited to you.


Q: Hi, I am 26 years old. I have been married for one year.  Everybody says that if you don’t conceive in the first year, it will create problems later. I want to take some time. If I wait longer than a year will there be any problem for me because of my age? Thanks.

A: You are welcome. Fertility is very high at 26 to 28 years old.  Assuming that you have regular cycles, no risk factors for tubal scarring, no history of endometriosis and your husband has a normal sperm count then you should have success if you wait more than a year. However, I don’t recommend waiting many years in case you have an unknown problem that does require diagnosis and medical help. Please see the third, seventh and eighth questions above for more information. 


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