Chapter 53

Infertility Record Sheet

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 of wife ______________________________________

Name of husband __________________________________

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 (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:

Treatment	Yes/No	How many	Date	Any success?
Ultrasound monitoring
Clomiphene stimulation with intercourse
Clomiphene stimulation with Insemination (IUI)
Injectable HMG stimulation with intercourse
Inseminations (IUI) without any stimulation
Injectable HMG stimulation with insemination (IUI)
In vitro fertilization (IVF)
ICSI

Give details of IVF / ICSI results, if applicable.

Stimulation protocol used	Follicles grown	Embryos formed	Embryos transferred	Embryos frozen

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

Credits: How to Have a Baby: Overcoming Infertility