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Free Infertility Opinion
Please take care to fill in all the required details.
Name of Wife
Name of Husband
Email Address


Please ensure that this is a valid email address. ( for example, abc @ xyz.com).
Where do you live ?
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 ?
Why do you think you are not getting pregnant (what is your diagnosis?) ?
FEMALE HISTORY
Age Birthdate ( eg 20 June 1971)
Height ( ft ) Weight ( kg)
Menstrual periods occur every days.
Are they regular ?
For how many days do you bleed ?
Number of miscarriages (abortions). Which year ? How many weeks pregnant were you ?
Medical problems and current medications of female partner:
MALE HISTORY
Age Birthdate( eg 20 June 1971)
Do you have problems with erection or ejaculation ?
Sperm count: million per ml. Motility %
Male medical problems and current medications. If you have an abnormal semen analysis report , please enter the details here. Provide as much detail as you can, including the dates of the reports.
 Please enter your details of your semen analysis report here.
MEDICAL TESTS
Have you had:
Test Date Result (enter values of blood test reports )
Hormonal blood tests.
FSH
LH
Prolactin
TSH
Other
MEDICAL TREATMENT
    How Many Date Any Success
In vitro fertilization (IVF)
   
ICSI
   
Give details of IVF / ICSI results, if applicable.


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