How long have you been trying to get pregnant?

How long have you been trying to get pregnant with doctor's consultation?

Reason for Infertility

FEMALE MEDICAL HISTORY

Are they regular?

For how many days do you bleed?

Have you been told you have endometriosis?

Have you ever had pelvic inflammatory disease (PID)?

Have you ever had pelvic surgery?

Number of Pregnancies with this partner

Number of Pregnancies with previous partner

Have you ever had a miscarriage? (abortions)

Did you have any tubal (ectopic) pregnancies?

Are there any live births?

Medical problems and current medications of female partner

MALE MEDICAL HISTORY

Are there any pregnancies with previous partner?

Do you have problems with erection or ejaculation?

Semen Analysis Report

Date

Sperm Count

Motility

Morphology

MEDICAL TESTS

Hysterosalpingogram (X-ray of the uterus and tubes)

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

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

Hormonal blood tests

FSH

LH

AMH (Anti Mullerian Hormone)

Prolactin

TSH

Other

MEDICAL TREATMENT

Ultrasound monitoring

Clomiphene stimulation with intercourse

Clomiphene stimulation with insemination (IUI)

HMG stimulation with intercourse

(IUI) without any stimulation

Injectable HMG stimulation with insemination (IUI)

In vitro fertilization (IVF)

ICSI

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

Questions and/or Comments