Infertility Record Sheet - a Medical Record of your treatment

This form can be useful to summarize and record your infertility history; and is very useful when you need to seek a second opinion.

Date ___ ___ ___ ___ ___ ___

Name ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Partner Name ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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? ___ ___ ___ ___ ___ ___

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:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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)

Give details of IVF / ICSI results, if applicable.

Stimulation protocol used

Follicles grown

Eggs retrieved

Embryos transferred

Embryos frozen

Are there other pertinent test results, procedures or problems that have been identified?