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Dr Malpani would be happy to provide a second opinion on your problem. Please fill in the following form, and email it to malpani@vsnl.com , or courier it (with a self-addressed stamped envelope enclosed with it), to:
Date __________________
Name of wife ______________________________________
Name of husband __________________________________
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:
| Test | Yes/No | Date | Resul |
|---|---|---|---|
| Hysterosalpingogram | | | |
| Laparoscopy | | | |
| Hysteroscopy | | | |
| Other | | | |
| 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?
© Dr. Aniruddha Malpani and Dr. Anjali Malpani www.drmalpani.com
Credits: How to Have a Baby: Overcoming Infertility
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