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Please take care to fill in all the required details.
Name of Wife
Name of Husband
Please ensure that this is a valid email address. (
abc @ xyz.com).
Where do you live ?
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 ?
Why do you think you are not getting pregnant (what is your diagnosis?) ?
Birthdate ( eg 20 June 1971)
Height ( ft )
Weight ( kg)
Menstrual periods occur every
Are they regular ?
For how many days do you bleed ?
Number of miscarriages (abortions). Which year ? How many weeks pregnant were you ?
Medical problems and current medications of female partner:
Birthdate( eg 20 June 1971)
Do you have problems with erection or ejaculation ?
million per ml.
Male medical problems and current medications. If you have an abnormal semen analysis report , please enter the details here. Provide as much detail as you can, including the dates of the reports.
Please enter your details of your semen analysis report here.
Have you had:
(enter values of blood test reports )
Hormonal blood tests.
In vitro fertilization (IVF)
Give details of IVF / ICSI results, if applicable.
Your question to the expert is:
Insert the word as shown :
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