Untitled Document

Are you looking for a free second opinion???

Please answer the following questions and we will be happy to help you out.

Name of Wife		Age
Name of Husband		Age

eMail ID

Place of Living

Married Life

How long have you been trying to get pregnant?

Have you been using any contraceptives?

Are seeking any doctor's advice?

Are you going to a gynaecologist or a family physician?

Do you know the cause/s for your infertilty?

Yes

Do you have regular menses?

Yes

Do you suffer from endometriosis?

Yes

Do you or anyone in your family suffer from tuberculosis?

Yes

Have you undergone any previous surgeries?

Yes

Any previous pregnancies ending in abortion?

Yes

Semen analysis report of male partner?

Sexual history? Does any of the partner have any dificulty during sexual intercourse?

Previous investigations?

HSG?

Laproscopy?

Hysteroscopy?

F.S.H.levels?

I.I.H. levels?

Prolactin levels?

T.S.H. levels?

Others?

Ultrasound?

Have you used tablets for ovulation induction? Do you know the names?

Any gonadotropin injections? Do you know the names?

Any previous cycles of IVF/ICSI in the past?

Number of eggs retrieved?

Number of embryos transferred?