Consult :.

     TIPS to fill the form:

  • Take printout and fill it first offline. Get your doctor help for full information.

  • All information supplied here is confidential as it will be answered by Dr. Anoop Gupta himself.

Your Name                    Name of Husband 
Email Address    Please ensure that this is a valid email address. We only reply by Mail.
Country/City of residence?          
How long have you been married?
Have you ever conceived?  
How long you are seeing a infertility Specialist ? 
Do you know specific reason of not getting pregnant?

FEMALE HISTORY

Age    Birthdate     Height ( ft )     Weight ( kg) 

Menstrual periods occur every days.  
For how many days do you bleed ?
Have you been told you have endometriosis/PCOD ?
Have you ever had pelvic inflammatory disease (PID) ?
Any pregnancies or miscarriage? How may days/weeks and when
Any D&C for any reason?
Any History of delayed Period?
Bleeding reduced over a period of time?
Any History of ectopic pregnancy?
Any History of Pelvic Surgery?
Any current medication?
Any Other problems?

MALE HISTORY

Age   Birthdate Wt :     Ht :

Any pregnancies. Which year ?
Do you have any sexual problems
OR any medical problem?
Sperm count: million per ml.     Motility %      Morphology : 
Any current medication?
   
MEDICAL TESTS Yes / No Date Result
Hysterosalpingogram ( X-ray of the uterus and tubes)     
Laparoscopy     
Hysteroscopy     
Hormonal blood tests     
FSH     
LH     
Prolactin     
TSH     
Other     
MEDICAL TREATMENT Yes / No How Many Date Any Success

Ultrasound monitoring 

  

(IUI) without any stimulation 

  

(IUI) with any stimulation (CC/HMG) 

  

In vitro fertilization (IVF) 

  

IVF-ICSI 

  

Assisted Hatching 

  
Give details of IVF / ICSI results, if applicable.  
Stimulation protocol used No. Of eggs retrieved Embryos formed Embryos transferred Embryos frozen
Quality of Embryos : The day of transfer : 

Any  Specific problems?

 Your  Specific query?