INFERTILITY
RECORD SHEET
from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD
and Dr. Anjali Malpani, MD.
table
of contents ·
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This form
can be useful to summarise and record your infertility history; and is
very useful when you need to seek a second opinion.
Date__________________
Name _____________________________________
Partner Name_______________________________
SOCIAL HISTORY
How long
have you been married?_____________
How long
have you been trying to get pregnant? ________________
How long
have you been trying to get pregnant with a doctor's help?_______________
Was it a
General Gynecologist or an Infertility Specialist? _________
About how
many times a month do you have intercourse? _____
Does either
partner smoke? _____________ How much? ___________
Does either
partner use recreational drugs? ________ Which ones? _____________________
FEMALE HISTORY
Age____ Birthdate
________ Height_________ Weight__________
Menstrual
periods occur every ________ days. Are they regular? __________
For how many
days do you bleed? _________ Do you have endometriosis? __________
Have you
ever had pelvic inflammatory disease (PID)?
_________________________________________________________________
What pelvic
surgeries have you had?
_________________________________________________________________
What were
the findings?
_________________________________________________________________
_________________________________________________________________
Number of
pregnancies with this partner _______
Number of
pregnancies with a previous partner _______
Number of
miscarriages _______
Number of
abortions __________
Number of
tubal pregnancies ________
Number of
live births _________
Medical problems
and current medications of female partner:
________________________________________________________________
_________________________________________________________________
MALE HISTORY
Age____ Birthdate
Number of
pregnancies with a previous partner _______
Do you have
problems with erection or ejaculation?
_______________________________
Sperm count:
____________ million per ml.
Motility
___________ %
Male medical
problems and current medications ____________________________________
____________________________________________________________________
MEDICAL
HISTORY
Have you
had:
Test
Yes/No Date
Result
Hysterosalpingogram
Laparoscopy
Hysteroscopy
Other
Treatment
Yes/No
How many Date
Any success?
Ultrasound
monitoring
Clomiphene
stimulation with intercourse
Clomiphene
stimulation with insemination
Injectable
HMG stimulation with intercourse
Inseminations
without any stimulation
Injectable
HMG stimulation with insemination
In vitro
fertilization ( IVF)
ICSI
Give details
of IVF / ICSI results, if applicable.
Stimulation
Follicles Embryos Embryos Embryos
protocol
used grown formed transferred frozen
OTHER
Are there
other pertinent test results, procedures or problems that have been identified?
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