- All fields are mandatory to be filled. If you don't have access to certain information, please put a hyphen ("-") into the field.
Information about female
General information
For example: 17/02/1973
Contact information
Please mark if you use Skype for Business
Street, House, Flat, ZIP, City
Medical information
Gynecological diseases, chronic diseases of inner organs or any other chronic diseases
If so, how many cigarettes per day?
If yes, please provide detailed information about diagnosis and operation
If yes, please, provide detailed information:
Year, has any pathology been found, has any surgery been performed?
Previous Pregnancies
Including deliveries, terminations, spontaneous pregnancy losses (miscarriages, missed abortions)
Please, attentively answer questions about each pregnancy, this is important
If you have more than 5 pregnancies please describe the last 5
First Pregnancy
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Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of missed abortion the fact that pregnancy has stopped may be found later
Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of cesarean please note the reason
Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Second Pregnancy
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Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of missed abortion the fact that pregnancy has stopped may be found later
Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of cesarean please note the reason
Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Third Pregnancy
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Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of missed abortion the fact that pregnancy has stopped may be found later
Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Fourth Pregnancy
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Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of missed abortion the fact that pregnancy has stopped may be found later
Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of cesarean please note the reason
Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Fifth Pregnancy
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Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of missed abortion the fact that pregnancy has stopped may be found later
Intensive and/or long lasting bleedings, fever, repeated curettage, antibiotics
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In case of cesarean please note the reason
Intensive and/or long lasting bleedings, fever, manual placenta removal, antibiotics
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Sixth Pregnancy
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Seventh Pregnancy
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Eighth Pregnancy
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Ninth Pregnancy
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Tenth Pregnancy
Natural delivery, cesarean section, miscarriage, termination
Number of weeks
Previous Fertility Treatment(s)
Please describe treatments you have had
IUI
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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 two IVF 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.
IVF No.1
DD/MM/YYYY
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 follicles and what size have been seen?
Frozen Embryo Transfer No.1.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.1.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.1.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.1.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.1.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.2
DD/MM/YYYY
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 follicles and what size have been seen?
Frozen Embryo Transfer No.2.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.2.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.2.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.2.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.2.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.3
DD/MM/YYYY
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 follicles and what size have been seen?
Frozen Embryo Transfer No.3.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.3.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.3.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.3.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.3.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.4
DD/MM/YYYY
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 follicles and what size have been seen?
Frozen Embryo Transfer No.4.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.4.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.4.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.4.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.4.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.5
DD/MM/YYYY
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 follicles and what size have been seen?
Frozen Embryo Transfer No.5.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.5.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.5.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.5.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.5.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.6
DD/MM/YYYY
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 follicles and what size have been seen?
Frozen Embryo Transfer No.6.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.6.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.6.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.6.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.6.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.7
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 follicles and what size have been seen?
DD/MM/YYYY
Frozen Embryo Transfer No.7.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.7.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.7.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.7.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.7.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.8
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 follicles and what size have been seen?
DD/MM/YYYY
Frozen Embryo Transfer No.8.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.8.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.8.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.8.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.8.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.9
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 follicles and what size have been seen?
DD/MM/YYYY
Frozen Embryo Transfer No.9.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.9.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.9.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.9.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.9.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.10
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 follicles and what size have been seen?
DD/MM/YYYY
Frozen Embryo Transfer No.10.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.10.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.10.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.10.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.10.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.11
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 follicles and what size have been seen?
DD/MM/YYYY
Frozen Embryo Transfer No.11.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.11.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.11.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.11.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.11.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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IVF No.12
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 follicles and what size have been seen?
DD/MM/YYYY
Frozen Embryo Transfer No.12.1.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.12.2.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.12.3.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.12.4.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Frozen Embryo Transfer No.12.5.
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Please write exactly on which date each medication has been started, in which dosage and until what date you've been taking it.
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Egg Donation treatment
Embryo Transfer No.1
Example: Day5, Blastocyst 2AA
Note for each date of ultrasound examination
Letrozole? Ovitrelle?
Embryo Transfer No.2
Example: Day5, Blastocyst 2AA
Note for each date of ultrasound examination
Letrozole? Ovitrelle?
Embryo Transfer No.3
Example: Day5, Blastocyst 2AA
Note for each date of ultrasound examination
Letrozole? Ovitrelle?
Embryo Adoption (Embryo Donation) treatmenta
Embryo Transfer No.1
Example: Day5, Blastocyst 2AA
Note for each date of ultrasound examination
Letrozole? Ovitrelle?
Embryo Transfer No.2
Example: Day5, Blastocyst 2AA
Note for each date of ultrasound examination
Letrozole? Ovitrelle?
Embryo Transfer No.3
Example: Day5, Blastocyst 2AA
Note for each date of ultrasound examination
Letrozole? Ovitrelle?
Your Partner
Information about Your Partner
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For example: 17/02/1973
Please mark if you use Skype for Business
Street, House, Flat, ZIP, City
Medical information
Gynecological diseases, chronic diseases of inner organs or any other chronic diseases
If so, how many cigarettes per day?
Please provide the following information from the latest sperm test
For example: 02/12/2018
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If yes, please provide detailed information about diagnosis and operation
If yes, please, provide detailed information:
Year, has any pathology been found, has any surgery been performed?
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This field is for validation purposes and should be left unchanged.