IVF and Egg donation

1. Do you have any serious illnesses or conditions which run in your family? *

YesNo

2. Have you ever had thrombosis or thrombophlebitis? *

YesNo

3. Have you had serious or reoccurring illnesses or repeated exams due to a specific condition in the past? *

YesNo

4. Have you ever had general anaesthesia? *

YesNo

5. Are you on any long-term medications? *

YesNo

6. Do you have any allergies? *

YesNo

7. Are you a smoker? *

YesNo

8. Previous Pregnancies? *

YesNo

Current partner or with previous

Pregnancy complications

End of pregnancy

Pregnancy

Notes (for example Caesarean section)

9. Age when periods first started (years) *

10. Frequency of your cycle (Example: regular, 28 days) *

11. How many days does your period last? *

12. Date of the last menstrual period *

13. Are your periods painful? *

YesNo

14. Have your periods ever stopped (excluding pregnancy)? *

YesNo

15. Does your gynaecologist regularly examine for breast cancer, cysts, myomas? *

YesNo

16. Do you attend periodical preventive gynaecological examinations? *

YesNo

17. Date of last PAP smear *

18. Has your gynaecologist informed you that your last PAP smear was normal? *

YesNo

19. Have you ever had an abnormal result? *

YesNo

20. Are you able to undergo hormonal treatment for IVF embryo transfer (ET) on hormonally prepared endometrium (HRT) and become pregnant according to your gynaecologist’s statement? *

YesNo

21. Contraception Pills

YesNo

Pill brand

Start date

End date

Intrauterine device

YesNo

Device type

Start date

End date

Other

YesNo

22. Have you had a history of Sexually transmitted disease *

YesNo

Pelvic inflammatory disease *

YesNo

Surgery on fallopian tubes *

YesNo

Removal of your appendix *

YesNo

Surgery on your cervix *

YesNo

Any other abdominal operations? *

YesNo

23. How long have you been trying to conceive? *

24. Have you had an ovulation induction with or without intrauterine insemination (IUI) *

YesNo

Cycle Date Clomid

Gonado-tropins

Sperm from

Pregnancy

Laparoscopy *

YesNo

Immunology *

YesNo

Coagulation (eg. Leiden mutation (Factor V)) *

YesNo

FII – prothrombin gene mutation *

YesNo

Hysteroscopy *

YesNo

Hysterosalpingogram (HSG) *

YesNo

Cystic fibrosis (CFTR) *

YesNo

Genetic examination (karyotype) *

YesNo

26. Other previous infertility investigations *

YesNo

27. Have you ever had In-Vitro Fertilization (IVF) (- Frozen embryo transfer (FET)) or treatment using donated oocytes (oocyte donation or OD) *

YesNo

Cycle Date

Eggs obtained Eggs fertilized Sperm from

No. of embryos transferred Pregnancy

28. Results of blood tests

Hormone Levels

TSH

Prolactin

Month / Year

FSH

LH

Estradiol

Month / Year

AMH (Please, specify units - ng/ml or pmol/l)

Month / Year

Personal data

Female

Male

Contact details

Phenotype information

Female

Male

Anamnesis – Female

Family

General Health

Gynaecological History

Infertility History

Anamnesis – Male

Family

General Health