Patient Name* Husband’s Name* Email* 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 have any surgeries in the past 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/surgery Sperm Count Million per ML Motility % Morphology Do you drink/ smoke/ use recreational drugs: MEDICAL TESTSYES / NODATERESULTHysterosalpingogram ( 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 TREATMENTYES / NOHOW MANYDATEANY SUCCESSUltrasound 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 usedNo. Of eggs retrievedEmbryos formedEmbryos transferredEmbryos frozenQuality of Embryos : The day of transfer : Any Specific problems? : Your Specific query? :
