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?
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
Date of Birth
Are there any pregnancies with previous partner?
Do you have problems with erection or ejaculation?
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)
AMH ( Anti Mullerian Hormone)
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)
Are there other pertinent test results, procedures or problems that have been identified?
Questions and/or Comments
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