Name
*
First Name
Last Name
Email
*
How do you plan to get pregnant?
I'm not sure
Naturally
Ovulation Induction
IUI with partners sperm
IUI with donor sperm
IVF with my own eggs
IVF with donor eggs
Surrogate
Do you have a partner?
I have a male partner and we will try to conceive together
I have a male partner but we will be using donor sperm
I don't have a male partner and will need to use sperm donation
How long have you been trying to conceive?
Have you confirmed you are ovulating (usually this is a blood test for progesterone on about day 21 of your cycle)?
Yes
No
Do you have menstrual periods?
Yes
No
How long are your cycles on average (from the start one bleed to the next)?
Are your cycles regular?
Have you recently done an IVF cycle?
Yes
No
Have you been diagnosed with PCOS?
Yes
No
Has your doctor tested your blood prolactin level? What were the results?
Has your doctor tested your thyroid hormones? What were the results?
Is there brown spotting in the second half of your cycle (spotting before your period starts in full flow)?
Yes
No
Is there irregular spotting (with no cyclical pattern)?
Yes
No
Do you have spotting or bleeding after sex?
Yes
No
Is your period
Very light and/or very short
Normal, profuse and bright red, lasting at least 3 days
Excessive bleeding/lasting more than 5 days
Do you have brown spotting at the end of your period?
Yes
No
Do you have significant pain in the second half of your cycle?
Yes
No
Do you have mid-cycle spotting?
Yes
No
Do you have very painful periods?
Yes
No
Have you had a blood test for FSH done on day 1-5 of your period? What were the results?
Did you have a test for LH done on day 1-5 of your period with your FSH test? What were the results?
Did you have a test for Estradiol done on day 1-5 of your period with your FSH test? What were the results?
Did you have a blood test for prolactin? What were the results?
Did you have a test for AMH run (any day of your cycle)? What were the results?
Have you done an ultrasound scan of the ovaries and uterus (including Aquascan/saline scan/SIS)? What were the results?
Do you have other findings from HSG, laparoscopy or HyCoSy?
Do you have findings from hysteroscopy?
Do you have an unusual or smelly discharge, itching or blisters on your genitals, burning on urination or sudden, severe abdominal pain with fever?
Yes
No
Do you have a fever and pelvic pain and/or other unusual discharge or symptoms, following unprotected sex with a new partner, delivery, C section, miscarriage, uterine surgery, investigation, IVF etc?
Yes
No
Do you have burning when you urinate and need to urinate more frequently than usual Do you have a thin, watery, grey discharge which smells unpleasant/fishy especially after sex?
Yes
No
Do you have itching and/or soreness around the genitals and/or a discharge and/or burning when you urinate?
Yes
No
Do you have a previous history of Chlamydia, PID, ectopic (tubal) pregancy or tubal blockage?
Yes
No
Have you ever previously been pregnant?
Yes
No
Do you have a history of repeat miscarriages/repeat chemical pregnancies/spontaneous loss?
Yes
No
Do you have a history of preeclampsia, placental abruption, growth restricted pregnancy, stillbirth, kidney disease, diabetes or a very high BMI?
Yes
No
Do you have a history of premature rupture of the membranes?
Yes
No
Do you have a history of premature labour?
Yes
No
Do you have a history of incompetent cervix (or unexplained preterm birth)?
Yes
No
Do you have a known history of endometriosis (or endometriomas/chocolate cysts on the ovaries) or symptoms of endometriosis (e.g. cyclical pelvic pain)?
Yes
No
Has your doctor screened for common infections (e.g. Chlamydia, Mycoplasma, Ureaplasma, Gardnerella)? What were the results?
Have you suffered repeat miscarriages/chemical pregnancies with any of the following symptoms occurring repeatedly - sore throat, skin rashes, fever, flu-like symptoms, joint pain?
Yes
No
Do you have other signs and symptoms of undiagnosed PCOS? What are they?
Has your doctor checked your progesterone blood level about 7 days after you ovulate (usually day 21 of a 28 day cycle or 7 days before you expect your period)? What were the results?
Has your doctor done a general health review for you to exclude diabetes (e.g. HbA1c), liver disease, anaemia, autoimmune disease (ANAs) etc? What were the results?
Has your doctor used an Aquascan or hysteroscopy to check for uterine problems (fibroids, polyps, septum, adenomyosis etc) and confirmed the tubes are not swollen (hydrosalpinx) on ultrasound? What were the results?
Has your doctor used an Aquascan or hysteroscopy to check for uterine problems (fibroids, polyps, septum, adenomyosis etc) and confirmed the tubes are not swollen (hydrosalpinx) on ultrasound? What were the results?
Has your doctor tested TSH, FT4 and antithyroid antibodies? What were the results?
Has your doctor run tests for thrombophilias (sticky blood) including antiphospholipid antibodies? What were the results?
Are you taking folate or folic acid (at least 400mcg) daily?
Yes
No
Unsure
List all supplements and/or medications you're currently taking
Do you eat a fairly balanced diet (high in vegetables, protein and complex carbohydrates, moderate in good fats, low in sugars and saturated fats)?
Yes
No
Unsure
Are you vegetarian?
Yes
No
Are you exposed to chemicals in your daily work? (e.g. hairdressers, nail technicians, industrial work)
Yes
No
Do you do night shift work?
Yes
No
Do you eat a diet including a lot of tuna fish, shark or other oily fishes at the top of the food chain, or high in shellfish?
Yes
No
Do you eat a diet which includes a lot of reduced fat foods?
Yes
No
Do you have a family or personal history of stroke, PE, DVT or other blood clots or diagnosed thrombophilias (e.g. Antiphospholipid antibodies, Hughes syndrome, Factor V Leiden, Protein S or C deficiency, MTHFR homozygote)? If yes, please specify and give details
Do you have unexplained abdominal bloating and a feeling of uncomfortable fullness that is persistent/getting worse?
Yes
No
Do you have blood in your stools or have been experiencing a persistent change in bowel habits?
Yes
No
Have you started suffering from unusual tiredness/feel constantly cold/have problems with weight gain/constipation/depression/slow movement or thought/muscle aches or weakness/muscle cramps/dry scaly skin/brittle hair and nails/loss of libido/heavier periods/shorter cycles/hair loss?
Yes
No
Have you started suffering from nervousness/irritability/increased perspiration/thinning of your skin/fine brittle hair/muscular weakness especially involving the upper arms and thighs/shaky hands/insomnia/racing heart/more frequent bowel movements/unexplained weight loss/lighter periods/longer cycles?
Yes
No
Do you feel unusually thirsty/need to frequently urinate/feel unusually tired/are losing weight/have recurrent thrush infections/suffer from cramps/constipation/recurrent skin infections?
Yes
No
Do you have any pre-existing medical conditions that you haven't discussed with your doctor with regards to pregnancy (e.g. diabetes, cancers, thyroid disease)?
Yes
No
Do you smoke?
Yes
No
Do you drink more than 1-2 units of alcohol more than once or twice a week? (A small glass of wine is roughly 2 units.)
Yes
No
Are you taking any medication that you have not recently discussed with your doctor for safety in pregnancy?
Yes
No
Do you have frequent unexplained bowel problems - constipation, pain, diarrhea?
Yes
No
Have you been diagnosed with homozygote MTHFR mutation or compound heterozygote mutation (genetic thrombophilias)?
Yes
No
Do you have a history of previous cervical surgery that you have not already discussed with regard to future pregnancies?
Yes
No
Do you drink more than 2 cups of coffee, tea, cola etc per day?
Yes
No
Do you have a history of appendicitis, bowel disease or surgery, pelvic or other abdominal infection?
Yes
No
His age
Does he work with chemicals or high temperatures?
Does he smoke?
Yes
No
Is he a moderate or heavy drinker?
Yes
No
Does he have pain on urination, pus from the head of the penis, or other signs of STIs?
Yes
No
Does he have a history of undescended testicles, mumps as an adult, inguinal hernia, testicular injury/surgery, very small testicles or any other male-hormone related problems?
Yes
No
Does he suffer from an inability to have penetrative sex or to ejaculate?
Yes
No
Does he have a previous live born child?
Yes
No
Has he fathered more than 2 previous pregnancies ending in unexplained miscarriage (taking into account previous partners)?
Yes
No
Did he previously have a vasectomy?
Yes
No
Does he suffer from diabetes?
Yes
No
Does he have a family history of cystic fibrosis?
Yes
No
Is he taking antidepressants, testosterone, anabolic steroids, opiates, colchicine, allopurinol, ketoconazole, spironolactone, nifepidine, cimetidine, sulfasalazine, propecia, finasteride, dutaseride, silodosin, tamsulosin, alfuzosin, hytrin, cardura, or other medications or recreational drugs (e.g. marijuana, anabolic steroids) that may affect the sperm quality?
Yes
No
Does he have any autoimmune diseases e.g. Crohn's, Ulcerative colitis, Coeliac, Rheumatoid arthritis, Psoriasis etc?
Yes
No
Does he eat a diet high in soya?
Yes
No
Does he eat a diet high in saturated fats (e.g. animal fats, palm oil)?
Yes
No
Does he have a sedentary lifestyle (e.g. desk work, long distance driving work), does he use a laptop on his lap or keep his mobile phone in his trouser pocket?
Yes
No
Has he done a sperm analysis recently? If yes, when?
Sperm analysis showed:
What did your doctor/consultant say about the result?
Did the sperm analysis show low semen volume (below 1.5ml), clumping/agglutination/failure to liquefy/positive MAR test/high viscosity/antisperm antibodies:
Yes
No
Sperm motility (progression/movement) showed:
Sperm morphology (shape/form) showed:
