Patient Registration Form

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Problem with egg quality Problem with fallopian tubes Previous tubal ligation (tubes tied) Uterine abnormality Problem with ovulation PCO – Polycystic Ovarian syndrome Premature ovarian failure Endometriosis History of multiple miscarriages Problem with partners sperm ( male factor infertility) Previous hysterectomy Unknown infertility Cancer diagnosis and desire to preserve fertility Other

IVF using my partners sperm (IVF) IVF using donors sperm (Sperm donation/SD) Use of Donors Eggs (Egg Donation/OD) Surgical extraction of my partners Sperm (TESA/TESE/PESA) Pre-implantation genetic diagnosis/screening (PGS/PGD) Gender selection (CS) Tandem Cycle Use of gestational carrier (surrogate mother) Plan to freeze eggs STEM CELL Other

YesNo

YesNo

Asthma Hyper tension (HT) Thyroid Disorder Other Diabetes No

YesNo

YesNo

AMHLHFSH TSHFT4Karyotype Blood GroupAnti TPOPRL VIT D3HSGSHS H/SL/S

T.TestDHEA17OHP KaryotypeBlood GroupSperm Test VolumeCountProgressive Motility Morphology