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Online Consultation, Form for free Gynecological, Infertility consultation
Dr Najeeb Layyous Clinique de FIV en Jordanie would be happy to provide a free online consultation to your problem. He will do his best to answer all queries. Please refer to Frequently Asked Questions before submitting your query.
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IN CASE YOU HAVE PRIVATE PROBLEMS Please email your details in the following format, so that he can guide you more effectively. The better the question you ask, the better his answer will be !
Copy and paste the form, fill in the details, and them email it to layyous@layyous.com
Date__________________
Name _____________________________________Occupation____________
Partner Name_______________________________
Home Phone ____________________ Business phone ________________Fax No____________
Address ________________________________________________________
E-Mail _____________________________________________
City _______________________ State _________________ Postal Code _________________
GENERAL HISTORY
How long have you been married?_____________
How long have you been trying to get pregnant? ________________
How long have you been trying to get pregnant with a doctor's help?___________
Was it a General Gynecologist or a Reproductive Endocrinology and Infertility Specialist? _________
About how many times a month do you have intercourse? _____
Does either partner smoke? _____________ How much? ___________
Does either partner use recreational drugs? ________ Which ones? _____________________
FEMALE HISTORY
Age_____ Birth date ________ Height_________ Weight_________
Blood group ______________________Allergies to medicines _________
Menstrual periods occur every ________ days. Are they regular? __________Amount of bleeding ____
For how many days do you bleed? _________ Do you have endometriosis? ______
Do you have any medical problems? ______ If yes, please give details, including any medications _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Have you ever had pelvic inflammatory disease (PID)? ______________________
What pelvic surgeries have you had? ____________________________________
What were the findings? _____________________________________________ ________________________________________________________________
Number of pregnancies with this partner _______
Number of pregnancies with a previous partner _______
Number of miscarriages _______
Number of abortions __________
Number of tubal pregnancies ________
Number of live births _________
TREATMENT HISTORY
Have you had:
|
Test |
Yes/No |
Result |
|
Hysterosalpingogram |
||
|
Laparoscopy |
||
|
Hysteroscopy |
|
Procedure |
Yes/No |
How many |
Any success? |
|
Clomiphene stimulation with intercourse |
|||
|
Clomiphene stimulation with insemination |
|||
|
Injectable FSH stimulation (Metrodin, Humegon, etc.) with intercourse |
|||
|
Injectable FSH stimulation with insemination |
|||
|
Inseminations without any stimulation |
|||
|
In vitro fertilization with ICSI |
OTHER
What else should we know about your case?
Are there other pertinent test results, procedures or problems that have been identified?
Give details of IVF results, if applicable:
-Stimulation Protocol _______________________________________
-No. of follicles ___________________________________________
-No. of eggs _____________________________________________
-No. of embryos transferred _________________________________
-No. of frozen embryos ____________________________________
-Out come ______________________________________________
MALE HISTORY
Age______________ Birth date ________________ Height ____________ Weight ________
Occupation ___________________ Allergies to medicines ______________ Blood group___
- Prior marriage __________________________________________________
- Number of pregnancies with a previous partner _________________________
- Do you have problems with evection or ejaculation ?_____________________
______________________________________________________________
- Male medical problem ___________________________________________
- Current medications _____________________________________________
- Hormonal blood test _____________________________________________
- Previous surgeries _______________________________________________
- Family history of infertility _________________________________________
- Previous treatment for infertility _____________________________________
- Semen analysis :
Volume ________________ PH _______________Date of test_____________
Liquefaction ________________
Count _____________________
Motility ________________ Type 1 ____________ Type 2 ___________
Type 3 ___________ Type 4 ___________
Normal forms __________________
WBCs _________________________ RBCs _________________________
If you had Azoospermia :
Have you ever had testicular biopsy ? _________________________________
Date __________________________
Result ________________________________________________________
_____________________________________________________________
Ask specific questions that you would like addressed.
_____________________________________________________________
_____________________________________________________________
E- mail or Fax us this form along with copies of your relevant medical records
Dr. Layyous will then review the material and make a written report (including recommendations). Alternatively, he will speak with you on the phone regarding your case - if you prefer.
Dr Najeeb Layyous F.R.C.O.G
Obstétricien consultant, gynécologue et spécialiste de l'infertilité
