Dr Malpani would be happy to provide a second opinion
on your problem. This is a free service I provide as a
labour of love ( I believe in
karma, and feel that by
helping you, I am helping myself ! )
Please fill in the following
details . This should take about 15 minutes. This is
basic medical information which every infertile couple
must know . While you don't have to fill in all the
information, please remember that the more the detail
you provide and the better the question you ask, the
better my answer will be ! If you don't understand any
of the terms, please read our free online book,
How to Have a Baby. You can also search
this site , which has over 300 pages of information !
If you cannot fill out this form, this means you need
to become better informed about your problem - please
review your medical records and talk to your doctor ! Keeping a
printout of the completed form will also help you talk
to your present doctor and get a second opinion from a
new doctor.
This form comes to me and I answer all my email
personally, so you can rest reassured that your privacy
and confidentiality are strictly maintained. It normally
takes me about 2 days to reply to your queries.
FEMALE HISTORY
Age
Birthdate ( eg 20 June
1971)
Height ( ft )
Weight ( kg)
Menstrual
periods occur every
days.
Are they
regular ?
For how many days do
you bleed ?
Have you been told you
have endometriosis ?
Have you ever had
pelvic inflammatory disease (PID) ?
What pelvic surgeries
have you had ? Which year ?
What were the findings
?
Number of pregnancies
with this partner. Which year ? What was the
outcome ?
Number of pregnancies
with a previous partner. Which year ? What
was the
outcome ?
Number of miscarriages
(abortions). Which year ? How many weeks
pregnant were you ?
Number of tubal (
ectopic) pregnancies. Which year ? What was
the outcome ?
Number of live births.
Which year ?
Medical problems and
current medications of female partner:
MALE HISTORY
Age
Birthdate( eg 20 June 1971)
Number of
pregnancies with a previous partner.
Which year ?
Do you have problems
with erection or ejaculation ?
Sperm count:
million per ml.
Motility
%
Male medical problems
and current medications. If you have an
abnormal semen analysis report , please
enter the details here. Provide as much
detail as you can, including the dates
of the reports.
Please enter your details of your semen
analysis report here.
MEDICAL TESTS
Have you had:
Test
Yes / No
Date
Result
Hysterosalpingogram
( X-ray of the uterus and tubes)
Yes
No
Laparoscopy
( telescope placed through the belly
button to see inside your abdomen)
Yes
No
Hysteroscopy (
telescope placed into the uterus through the
vagina to see the inside of the uterus)
Yes
No
Hormonal blood tests.
Yes
No
Please enter the values of your blood
test reports below.
FSH
Yes
No
LH
Yes
No
Prolactin
Yes
No
TSH
Yes
No
Other
Yes
No
MEDICAL TREATMENT
How Many
Date
Any Success
Ultrasound
monitoring
Yes
No
Clomiphene
stimulation with intercourse
Yes
No
Clomiphene
stimulation with insemination (IUI)
Yes
No
HMG
stimulation with intercourse
Yes
No
(IUI)
without any stimulation
Yes
No
Injectable
HMG stimulation with insemination (IUI)
Yes
No
In vitro
fertilization (IVF)
Yes
No
ICSI
Yes
No
Give details
of IVF / ICSI results, if applicable.
Stimulation protocol used
Follicles grown
Embryos formed
Embryos transferred
Embryos frozen
Are there other pertinent test
results, procedures or problems that have been
identified?
My question (try to keep this as specific as possible
, please !) to Dr Malpani is:
HOW TO HAVE A BABY
This comprehensive, but easy-to-understand,book
offers new hope for infertile couples.
