Reason for Infertility?

Are they regular?

Yes No

For how many days do you bleed?

Have you been told you have endometriosis?

Yes No

Have you ever had pelvic inflammatory disease (PID)?

Yes No

Have you ever had pelvic surgery?

Yes No

Number of Pregnancies with this partner

Number of Pregnancies with previous partner

Have you ever had a miscarriage?(abortions)

Yes No

Did you have any tubal (ectopic) pregnancies?

Yes No

Are there any live births?

Yes No

Medical problems and current medications of female partner

Date of Birth

Are there any pregnancies with previous partner?

Yes No

Do you have problems with erection or ejaculation?

Yes No

Date

Sperm Count

Motility

Morphology

Hysterosalpingogram( X-ray of the uterus and tubes)

Yes No

Laparoscopy ( telescope placed through the belly button to see inside your abdomen)

Yes No

Hysteroscopy ( telescope placed into the uterus through the vagina to see the inside of the uterus)

Yes No

FSH

Yes No

LH

Yes No

AMH ( Anti Mullerian Hormone)

Yes No

Prolactin

Yes No

TSH

Yes No

Other

Yes No

Ultrasound monitoring

Yes No

Clomiphene stimulation with intercourse

Yes No

Clomiphene stimulation with insemination (IUI)

Yes No

HMG stimulation with intercourse

Yes No

(IUI) without any stimulation

Yes No

Injectable HMG stimulation with insemination (IUI)

Yes No

In vitro fertilization (IVF)

Yes No

ICSI

Yes No

Are there other pertinent test results, procedures or problems that have been identified?

Questions and/or Comments

History

FEMALE MEDICAL HISTORY

MALE MEDICAL HISTORY

Semen Analysis Report:

MEDICAL TESTS

Hormonal blood tests

MEDICAL TREATMENT

News