Medical Questionnaire – O.L.G.A. Fertility Clinic

All fields are mandatory to be filled. If you don't have access to certain information, please put a hyphen ("-") into the field.

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With Partner
Single

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I need access to Catalogue of Egg Donors

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Which treatment are you looking for?

Own egg IVF
Egg Donation
Embryo Adoption
I need medical advice
Other

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Language

en
ru

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I'm interested in Introductory Package

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Your comments about treatment

Information about female

General information

Your Name (as written in your passport)*

First Name Last Name

Ваш пол*

Женский

Фамилия Имя Отчество*

Date of Birth*

For example: 17/02/1973

Nationality

Educational level

Образование*

Occupation

This information is needed to assess whether you have factors that affect your health.

Contact information

Email*

Mobile Phone*

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Home Phone

Country*

Address of Residence*

Street, House, Flat, ZIP, City

Medical information

Height (cm)*

Weight (kg)*

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Eye colour

Hidden

Hair colour

Blood group*

Rhesus factor*

Diseases

Do you have currently or used to have in the past one or more of the following diseases?

Arterial hypertension*

No
Yes

Arterial hypertension

So that we can understand your risks in fertility treatment and pregnancy related to arterial hypertension, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Heart disease*

No
Yes

Heart disease

So that we can understand your risks in fertility treatment and pregnancy related to heart disease, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Lung disease*

No
Yes

Lung disease

So that we can understand your risks in fertility treatment and pregnancy related to lung disease, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Kidney disease*

No
Yes

Kidney disease

So that we can understand your risks in fertility treatment and pregnancy related to kidney disease, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Liver disease*

No
Yes

Liver disease

So that we can understand your risks in fertility treatment and pregnancy related to liver disease, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Hepatitis*

No
Yes

Hepatitis

So that we can understand your risks in fertility treatment and pregnancy related to hepatitis, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

HIV*

No
Yes

HIV

So that we can understand your risks in fertility treatment and pregnancy related to HIV, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Rheuma*

No
Yes

Rheuma

So that we can understand your risks in fertility treatment and pregnancy related to rheuma, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Reumatism or another immune (autoimmune) disorder*

No
Yes

Reumatism or another immune (autoimmune) disorder

So that we can understand your risks in fertility treatment and pregnancy related to reumatism or another immune (autoimmune) disorder, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Diabetes*

No
Yes

Diabetes

So that we can understand your risks in fertility treatment and pregnancy related to diabetes, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Nervous system disorder (epilepsy, multiple sclerosis etc.)*

No
Yes

Nervous system disorder (epilepsy, multiple sclerosis etc.)

So that we can understand your risks in fertility treatment and pregnancy related to nervous system disorder (epilepsy, multiple sclerosis etc.), advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Conditions in your past

Have you had one or more of the following conditions in your past

Oncology (cancer)*

No
Yes

Oncology (cancer)

So that we can understand your risks in fertility treatment and pregnancy related to oncology (cancer), advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Removal of a "birthmark"*

No
Yes

Removal of a "birthmark"

So that we can understand your risks in fertility treatment and pregnancy related to birthmark / removal of a birthmark, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Thrombosis / heart attack / stroke*

No
Yes

Thrombosis / heart attack / stroke

So that we can understand your risks in fertility treatment and pregnancy related to thrombosis / heart attack / stroke, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

Mental (psychiatric) disorder*

No
Yes

Mental (psychiatric) disorder

So that we can understand your risks in fertility treatment and pregnancy related to mental (psychiatric) disorder, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have you got this diagnosis for the first time?

What is the name and the contacts of the specialist who follows, treats and advises you in relation to the above disease?

Has your condition improved, remained stable or became worse?

What medication, doses and regimen did you take in the past?

What medication, dosages and regimen do you take currently?

--------

First-degree relatives' conditions in the age under 50

Have any of your first-degree relatives had the following conditions in the age under 50?

Thrombosis*

No
Yes

Thrombosis

So that we can understand your risks in fertility treatment and pregnancy related to thrombosis of your relative, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have he/she got this diagnosis for the first time?

Any additional information you can provide

--------

Heart attack*

No
Yes

Heart attack

So that we can understand your risks in fertility treatment and pregnancy related to heart attack of your relative, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have he/she got this diagnosis for the first time?

Any additional information you can provide

--------

Stroke*

No
Yes

Stroke

So that we can understand your risks in fertility treatment and pregnancy related to stroke of your relative, advise you about the risk and reduce it if possible, we kindly ask you to answer the questions:

What is the diagnosis?

When have he/she got this diagnosis for the first time?

Any additional information you can provide

--------

Other medical conditions

Please list any other medical conditions you may have*

Gynecological diseases, chronic diseases of inner organs or any other chronic diseases

Do you take any medication regularly?*

Do you have any allergies?*

Do you smoke?*

If so, how many cigarettes per day?

Have you had surgery in the abdominal area?*

If yes, please provide detailed information about diagnosis and operation

Have you had hysteroscopy before?*

If yes, please, provide detailed information: Year, has any pathology been found, has any surgery been performed?

How long is your menstrual cycle?*

When was the first day of the last menstruation?*

Do you take any hormonal medication?*

Previous Pregnancies

Have you ever been pregnant?

No
Yes

How many pregnancies have you had?*

Including deliveries, terminations, spontaneous pregnancy losses (miscarriages, missed abortions)

Please, attentively answer questions about each pregnancy, this is important

If you have more than 10 pregnancies please describe the last 10 from latest to earliest

First Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Current partner*

Yes
No

Outcome*

Natural delivery, cesarean section, miscarriage, termination

Duration of pregnancy*

Number of weeks

P 2

Add Pregnancy

Second Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Current partner*

Yes
No

Outcome*

Natural delivery, cesarean section, miscarriage, termination

Duration of pregnancy*

Number of weeks

P 3

Add Pregnancy

Third Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean? In case of cesarean please note the reason.*

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Current partner*

Yes
No

Outcome*

Natural delivery, cesarean section, miscarriage, termination

Duration of pregnancy*

Number of weeks

P 4

Add Pregnancy

Fourth Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Current partner*

Yes
No

Outcome*

Natural delivery, cesarean section, miscarriage, termination

Duration of pregnancy*

Number of weeks

P 5

Add Pregnancy

Fifth Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Current partner*

Yes
No

Outcome*

Natural delivery, cesarean section, miscarriage, termination

Duration of pregnancy*

Number of weeks

Sixth Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Seventh Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Eighth Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Ninth Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Tenth Pregnancy

Year*

What was the outcome of this pregnancy?

Termination
Spontaneous pregnancy loss
Delivery

--------

At which pregnancy term (in weeks) have you had termination?*

Termination was done with the help of medication (intake of cytotec tablet/s) or surgically (curettage, scraping)?*

Have you had any complications after the termination?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which pregnancy term (in weeks) has this pregnancy stopped and at which pregnancy term has this been diagnosed?*

In case of missed abortion the fact that pregnancy has stopped may be found later

Please choose which sentence is applicable to your situation*

Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no fetal sack available in the uterine cavity
Bleeding started first, ultrasound was done after bleeding started, ultrasound examination has confirmed that no heartbeat
There was no bleeding

--------

Planned ultrasound examination has found:

No fetal sack in the uterine cavity
Empty fetal sack
No fetal heart beat

--------

After ultrasound examination has confirmed that pregnancy has stopped, for the purpose of cleaning uterine cavity from fetal tissue the following treatment has been done:*

Cytotec tablets
Curettage (scraping)
No treatment

Have you had any complications after?*

Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics

--------

At which term of pregnancy (how many weeks of pregnancy?) has the delivery taken place?*

Natural delivery, emergency or planned cesarean?*

In case of cesarean please note the reason

Have you had any complications?*

Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics

Previous Fertility Treatment(s)

Please describe treatments you have had

Have you had any fertility treatment?*

No
Yes

Fertility Treatment(s)*

IUI
IVF/ICSI
Egg donation
Embryo adoption

IUI

Date*

Outcome*

IUI 2

Add IUI

-------

Date*

Outcome*

IUI 3

Add IUI

-------

Date*

Outcome*

IVF/ICSI

To calculate potential amount of attempts with own eggs till live birth in general we need to know

Your date of birth (age), which tells us the what proportion of your embryos on day 5 (blastocysts) is expected to have normal amount of chromosomes (being usable)
Your AMH which tells us how many embryos per one egg retrieval we may get.

Your individual information from the past IVF(s) is very valuable for several reasons:

To understand if your individual expected outcome of one IVF is better or worse than the estimation for your age and AMH level;
To understand if we can see anything in your previous IVF process which can be significantly improved.

How many egg retrievals have you had altogether?*

How many fresh embryo transfers have you had altogether?*

How many frozen embryo transfers have you had altogether?*

Please fill in information about the last 8 IVFs

Результат АМГ (антимюллеров гормон)

Дата анализа

IVF No.1

What was the date of your egg retrieval?*

DD/MM/YYYY

What clinic?*

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.1.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 1.2

Add frozen embryo transfer

Frozen Embryo Transfer No.1.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 1.3

Add frozen embryo transfer

Frozen Embryo Transfer No.1.3.

Date of the Embryo Transfer

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?

On which day of embryonic development the embryo(-s) have been frozen?

On which day of embryonic development the embryo(-s) have been transferred?

What was the outcome?

FET 1.3

Add frozen embryo transfer

Frozen Embryo Transfer No.1.4.

Date of the Embryo Transfer

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?

On which day of embryonic development the embryo(-s) have been frozen?

On which day of embryonic development the embryo(-s) have been transferred?

What was the outcome?

FET 1.4

Add frozen embryo transfer

Frozen Embryo Transfer No.1.5.

Date of the Embryo Transfer

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?

On which day of embryonic development the embryo(-s) have been frozen?

On which day of embryonic development the embryo(-s) have been transferred?

What was the outcome?

--------

IVF 2

Add IVF Attempt

IVF No.2

What was the date of your egg retrieval?*

DD/MM/YYYY

What clinic?*

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.2.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 2.2

Add frozen embryo transfer

Frozen Embryo Transfer No.2.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 2.3

Add frozen embryo transfer

Frozen Embryo Transfer No.2.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?

On which day of embryonic development the embryo(-s) have been frozen?

On which day of embryonic development the embryo(-s) have been transferred?

What was the outcome?

FET 2.4

Add frozen embryo transfer

Frozen Embryo Transfer No.2.4.

Date of the Embryo Transfer

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?

On which day of embryonic development the embryo(-s) have been frozen?

On which day of embryonic development the embryo(-s) have been transferred?

What was the outcome?

FET 2.5

Add frozen embryo transfer

Frozen Embryo Transfer No.2.5.

Date of the Embryo Transfer

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?

On which day of embryonic development the embryo(-s) have been frozen?

On which day of embryonic development the embryo(-s) have been transferred?

What was the outcome?

--------

IVF 3

Add IVF Attempt

IVF No.3

What was the date of your egg retrieval?*

DD/MM/YYYY

What clinic?*

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.3.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 3.2

Add frozen embryo transfer

Frozen Embryo Transfer No.3.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 3.3

Add frozen embryo transfer

Frozen Embryo Transfer No.3.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 3.4

Add frozen embryo transfer

Frozen Embryo Transfer No.3.4.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 3.5

Add frozen embryo transfer

Frozen Embryo Transfer No.3.5.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

--------

IVF 4

Add IVF Attempt

IVF No.4

What clinic?*

What was the date of your egg retrieval?*

DD/MM/YYYY

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.4.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 4.2

Add frozen embryo transfer

Frozen Embryo Transfer No.4.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 4.3

Add frozen embryo transfer

Frozen Embryo Transfer No.4.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 4.4

Add frozen embryo transfer

Frozen Embryo Transfer No.4.4.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 4.5

Add frozen embryo transfer

Frozen Embryo Transfer No.4.5.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

--------

IVF 5

Add IVF Attempt

IVF No.5

What clinic?*

What was the date of your egg retrieval?*

DD/MM/YYYY

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.5.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 5.2

Add frozen embryo transfer

Frozen Embryo Transfer No.5.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 5.3

Add frozen embryo transfer

Frozen Embryo Transfer No.5.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 5.4

Add frozen embryo transfer

Frozen Embryo Transfer No.5.4.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 5.5

Add frozen embryo transfer

Frozen Embryo Transfer No.5.5.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

--------

IVF 6

Add IVF Attempt

IVF No.6

What clinic?*

What was the date of your egg retrieval?*

DD/MM/YYYY

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.6.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 6.2

Add frozen embryo transfer

Frozen Embryo Transfer No.6.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 6.3

Add frozen embryo transfer

Frozen Embryo Transfer No.6.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 6.4

Add frozen embryo transfer

Frozen Embryo Transfer No.6.4.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 6.5

Add frozen embryo transfer

Frozen Embryo Transfer No.6.5.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

--------

IVF 7

Add IVF Attempt

IVF No.7

What clinic?*

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

What was the date of your egg retrieval?*

DD/MM/YYYY

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.7.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 7.2

Add frozen embryo transfer

Frozen Embryo Transfer No.7.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 7.3

Add frozen embryo transfer

Frozen Embryo Transfer No.7.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 7.4

Add frozen embryo transfer

Frozen Embryo Transfer No.7.4.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 7.5

Add frozen embryo transfer

Frozen Embryo Transfer No.7.5.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

--------

IVF 8

Add IVF Attempt

IVF No.8

What clinic?*

Have you done this treatment together with your current partner, your former partner or a sperm donor?*

Current partner
Former partner
Sperm donor

What medication have you been using daily to grow your eggs?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

How many ultrasound examinations have been done and on which dates?*

How many follicles and what size have been seen?

What was the date of your egg retrieval?*

DD/MM/YYYY

How many eggs have been collected, how many of them were mature, how many have got normally fertilized?*

What was the methode of fertilization (IVF/ICSI)?*

How many embryos were available on day 2/3/5? What was their quality/morphology?*

How many embryos were transferred fresh?*

What was the outcome of the embryo transfer?*

Were there any embryos frozen?*

Were there any frozen embryo transfer(s) from this IVF cycle?*

No
Yes

Frozen Embryo Transfer No.8.1.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 8.2

Add frozen embryo transfer

Frozen Embryo Transfer No.8.2.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 8.3

Add frozen embryo transfer

Frozen Embryo Transfer No.8.3.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 8.4

Add frozen embryo transfer

Frozen Embryo Transfer No.8.4.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

FET 8.5

Add frozen embryo transfer

Frozen Embryo Transfer No.8.5.

Date of the Embryo Transfer*

Was embryo transfer done in a natural cycle or in a cycle with hormonal treatment?*

In a natural cycle
In a cycle with hormonal treatment

--------

Please specify what hormonal treatment was used?*

Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.

--------

How many embryos have been transferred?*

On which day of embryonic development the embryo(-s) have been frozen?*

On which day of embryonic development the embryo(-s) have been transferred?*

What was the outcome?*

--------

Egg Donation treatment

What clinic?*

What was the age of the egg donor?*

How many eggs have you got and how many got normally fertilized?*

How many blastocysts have you got?*

How many embryo transfers have you had?*

Please describe your first 5 embryo transfers

Embryo Transfer No.1

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.2

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.3

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.4

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.5

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Adoption (Embryo Donation) treatment

What clinic?*

How many embryo transfers of donor embryo have you had?*

Please describe your first 5 embryo transfers

Embryo Transfer No.1

Was an embryo donated by fertility patients or created from eggs and sperm of healthy professional donors?*

What was the age of the egg donor?*

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tiff, tif, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.2

Was an embryo donated by fertility patients or created from eggs and sperm of healthy professional donors?*

What was the age of the egg donor?*

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tiff, tif, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.3

Was an embryo donated by fertility patients or created from eggs and sperm of healthy professional donors?*

What was the age of the egg donor?*

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tiff, tif, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.4

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Embryo Transfer No.5

Was embryo fresh or frozen?*

Fresh
Frozen

Which date embryo transfer has been done?*

What was embryo’s day of development and morphology*

Example: Day5, Blastocyst 2AA

Which dates ultrasound examinations have been done?*

What was the thickness of endometrium on each date?*

Was endometrium 3-layer?*

Note for each date of ultrasound examination

If pictures of ovaries and uterus are available please provide

Drop files here or

Accepted file types: jpg, gif, png, pdf, tif, tiff, Max. file size: 200 MB, Max. files: 10.

What was preparation for the ET?*

In natural cycle
In hormonally controlled cycle

Has any medication been used for stimulation of ovulation in the FET cycle*

Letrozole? Ovitrelle?

What day after ovulation was embryo transfer done?*

What method was used to confirm ovulation?*

Urine test for LH peek
Ultrasound examination

What medication was given after embryo transfer and in which dosages?*

What medication has been used and in which dosages?*

Which dates each of medicines was started and finished?*

Your Partner

Partner*

No partner
Male partner
Female partner

Information about Your Partner

--------

Фамилия, Имя, Отчество партнера*

--------

Partner Name (as written in your passport)*

First Name Last Name

Date of Birth*

For example: 17/02/1973

Nationality

Educational level

Occupation

Email*

Mobile Phone*

Skype

Please mark if you use Skype for Business

Country

Address of Residence

Street, House, Flat, ZIP, City

Medical information

Height (cm)*

Weight (kg)*

Blood group*

Rhesus factor*

Please list any medical conditions you may have

Chronic diseases of inner organs or any other chronic diseases

Do you take any medication regularly?

Do you have any allergies?

Do you smoke?

If so, how many cigarettes per day?

Do you have children / did you have pregnancies in previous relations?*

Did you have a Sperm test?*

Yes
No

Please provide the following information from the latest sperm test

The date of the sperm test*

For example: 02/12/2018

Volume, ml*

Concentration mln/ml*

Percentage of progressively moving spermatozoa(А+В) %*

Percentage of morphologically normal shaped spermatozoa %*

---------

Have you had surgery in the abdominal area

If yes, please provide detailed information about diagnosis and operation

Have you had hysteroscopy before?

If yes, please, provide detailed information: Year, has any pathology been found, has any surgery been performed?

How long is your menstrual cycle?

When was the first day of the last menstruation?

Do you take any hormonal medication?

Hidden

--------

Пожалуйста, подтвердите свое согласие на обработку персональных данных*

Подтверждаю свое согласие на обработку персональных данных в соответствии с Федеральным законом от 27.07.2006 г. № 152-ФЗ «О персональных данных». (ФИО, вся личная, контактная и медицинская информация данной Анкеты)

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Name

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