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+91-8826611254

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eConsult Detail

Home eConsult

Please take a print out of the form & fill it up with your doctor's help.

*All detail inputs are compulsory.

*Patient Name:

*Husband's Name:

*E-mail:

*Country of residence:

How long have you been married (Years):

How long have you been seeing an Infertility expert (Years):

Are you aware of a specific reason for not getting pregnant:

Female History:

Age:

Birth Date:

Height:

Weight:

Menstrual days occur every:

For how many days do you bleed:

Do you suffer from Endometriosis/ PCOD:

Have you had any miscarriage:

Do you have a history of pelvic disease:

Are you a diabetic:

Do you suffer from thyroid disease:

Any known medical problem:

Do you drink/ smoke/ use recreational drugs:

Male History:

Age:

Birth Date:

Height:

Weight:

Do you have any sexual or medical problems:

Any known medical problem:

Sperm Count :

million per ML.

Motility:%

Morphology:

Do you drink/ smoke/ use recreational drugs:

Medical Test Report:

MEDICAL TESTS	YES / NO	DATE	RESULT
Hysterosalpingogram ( X-ray of the healthy tubes)	Yes No
Laparoscopy	Yes No
Hysteroscopy	Yes No
Hormonal blood tests	Yes No
FSH	Yes No
LH	Yes No
Prolactin	Yes No
TSH	Yes No
AMH	Yes No
Other	Yes No

MEDICAL TREATMENT	YES / NO	HOW MANY	DATE	ANY SUCCESS
Ultrasound monitoring	Yes No
(IUI) without any stimulation	Yes No
(IUI) with any stimulation (CC/HMG)	Yes No
In vitro fertilization (IVF)	Yes No
IVF-ICSI	Yes No
Assisted Hatching	Yes No
Give details of IVF / ICSI results, if applicable.
Stimulation protocol used	No. Of eggs retrieved	Embryos formed	Embryos transferred	Embryos frozen

Quality of Embryos :		The day of transfer :
Any Specific problems? :		Your Specific query? :

Dr. Brig R.K Sharma

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10000

- Babies

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Timings for Appointment

Monday to Saturday - 11.00am to 1.00pm

Timings for Consultancy

Monday to Saturday - 10.30am to 4.00pm

Evening OPD Address

Maa Fertility Center C2/312 Janakpuri, Near Dabri Mor Metro Station, New Delhi

Contact Us

Dr. (Brig.) R.K. Sharma

Address : 2, Chandragupta Marg, Chanakyapuri, New Delhi- 110021, India
Phone : Mr. Azad - International IVF Coordinator
+91-8130735651
+91-8826611254
Email : info@drrksharmaivf.in

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