Dr. Singh Test Tube Baby Centre

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All information supplied here is confidential as it will be answered by Dr. ShashiSingh/
Dr. Anirudh Singh

Your Name

Name of Husband

E-mail

Country/City of residence?

How long have you been married?

Have you ever conceived?

How long you are seeing a infertility Specialist ?

Do you know specific reason of not getting pregnant?

FEMALE HISTORY

Age

Birthdate

Height
(ft)

Weight
(kg)

Menstrual periods occur every

Days

For how many days do you bleed ?

Have you been told you have endometriosis/PCOD ?

Have you ever had pelvic inflammatory disease (PID) ?

Any pregnancies or miscarriage? How may days/weeks
and when

Any D&C for any reason?

Any History of delayed Period?

Bleeding reduced over a period of time?

Any History of ectopic pregnancy?

Any History of Pelvic Surgery?

Any current medication?

Any Other problems?

MALE HISTORY

Age (Male)

Birthdate

Height
( ft )

Weight
( kg)

Any pregnancies. Which year ?

Do you have any sexual problems OR any medical problem?

Sperm count

million per
ml.

Motility

Morphology

Any current medication?

MEDICAL TESTS

Yes / No

Date

Result

Hysterosalpingogram ( X-ray of the uterus and tubes)

Laparoscopy

Hysteroscopy

Hormonal blood tests

FSH

Prolactin

TSH

Other

MEDICAL TREATMENT

Yes / No

How Many

Date

Any Success

Ultrasound monitoring

(IUI) without any stimulation

(IUI) with any stimulation (CC/HMG)

In vitro fertilization (IVF)

IVF-ICSI

Assisted Hatching

Give details of IVF / ICSI results, if applicable.

Stimulation protocol used

No. Of eggs retrieved

Embryos formed

Embryos frozen

Quality of Embryos

The day of transfer

Any Specific problems?

Your Specific query?