PMA-FR Form 1

Full Name

Country of Residence*

Phone Number*

Email *

Are you married?*

Yes

Duration of Infertility*

Is there a known cause for the infertility?*

Is there a known health issue for either partner?*

Yes

No

If yes, please provide details

Female Partner's Age*

Do you have children?*

Yes

No

If yes, please provide details

Have you been pregnant before?*

Yes

No

If yes, how many times?

If yes, did the pregnancies result in a live birth or a miscarriage?

Have you had a laparoscopy or hysteroscopy?*

Yes

No

If yes, please specify the date.

If yes, please provide the results.

Do you have a regular menstrual cycle?*

Yes

No

If no, please specify the frequency and duration of your irregular cycles.

Have you had any previous fertility treatments?*

Yes

No

If yes, please indicate the number of cycles.

Has a sperm analysis been performed?*

Yes

No

If yes, please provide the date of the report.

If there is a low sperm count, please state the number.

Has the male partner had any surgery related to infertility?

Yes

No

If yes, please provide details of the surgery.

PMA-IVF Medical Form