The Future of Infertility Treatments

Female Forms

One-Month Basal Body Temperature Record

Chlamydia titer_______________________
Date______________

Hysterosalpingogram: Date__________
Result_________________

________________________________________________________

Oil soluble contrast used?__________

Laparoscopy: Date__________ Findings and treatment _________ ________________________________________________________ ________________________________________________________

Date__________ Findings and treatment ______________________ ________________________________________________________ ________________________________________________________ ________________________________________________________

Prolactin level:________ Date ________
Treatment______________

Repeat levels: ________ Date ________
Treatment__________________________________ Date ________
Treatment______________ TSH level: ________ Date ________
Treatment______________ Repeat levels: ________ Date ________
Treatment_____________ _____________________ Date ________
Treatment_____________
Other Thyroid evaluation: ___________________________________
Notes: __________________________________________________

Day 3 FSH level: ________ Date _________

Level: _________________ Date _________

Clomiphene citrate challenge test:
Date________ Day 3 FSH:_____
Day 10 FSH: ________ Interpretation_________________________
Date________________ Day 3 FSH:___________________
Day 10 FSH: ________ Interpretation_________________________

Notes and Other Information:_______________________________ _______________________________________________________

Ovluation Induction Attempts
Date (day 1 of cycle) ________
Medication:_______________________ Dose_________________
Day of cycle medication begun: _____________________________

Ultrasound:
Day of cycle________ Results_____________________
Day of cycle________ Results_____________________
Day of cycle________ Results_____________________
Day of cycle________ Results_____________________

Estradiol: Day of cycle________ Level______________________
Day of cycle________ Results_____________________
Day of cycle________ Results_____________________
hCG given: Day of cycle________ Dose______________________
Endometrial thickness day of hCG: ________ mm

Progesterone level: Day of cycle ________ Level ________

Inseminations? _____ # _____ Semen values___________________
________________________________________________________

Date of pregnancy test________ Result ________
Date menses began ________

Notes:__________________________________________________ _______________________________________________________

ART PROCEDURES

Date:________
Procedure:_________________________________

ART Center:____________________________________________

GnRH agonist? __________ Dose _____ Started on day _____ of cycle
Gonadotropin dose:_______________________________________
Peak estradiol:________ hCG given on cycle day: _____ dose _____
Endometrial thickness day of hCG: ________mm

Number of mature follicles on ultrasound: _____________________
Number of eggs retrieved: ________ Egg quality:_______________
Semen analysis at time of procedure: Vol _____ cc Total count _____
Motility _____ Morphology ________
Notes___________________

ICSI? _______________

# of eggs transferred (GIFT): _____ # of eggs fertilized (IVF/ZIFT): _____
# of zygotes/embryos transferred: __________
# of embryos cryopreserved:______________
Progesterone level: ______ hCG level: ______ Date: ______
hCG level: ______ Date: ______
Notes:_________________________________________________ _______________________________________________________ _______________________________________________________