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Chapter 53
INFERTILITY RECORD SHEET

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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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?

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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