Female History

Male History

Sperm Count

MEDICAL TESTS YES / NO DATE RESULT
Hysterosalpingogram ( X-ray of the healthy tubes)(HSG) YesNo
Laparoscopy YesNo

Hysteroscopy YesNo

Hormonal blood tests YesNo
FSH YesNo
LH YesNo
Prolactin YesNo
TSH YesNo
AMH YesNo

Other YesNo

MEDICAL TREATMENT YES / NO HOW MANY DATE ANY SUCCESS
Ultrasound monitoring YesNo
(IUI) without any stimulation YesNo
(IUI) with any stimulation (CC/HMG) YesNo
In vitro fertilization (IVF) YesNo
IVF-ICSI YesNo
Assisted Hatching YesNo
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? :