PMA-FR Form 2

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.

Assisted Reproductive Technology (ART) Medical Form