Fertility Test Questions

Female Questions:

Response

Have you had unprotected intercourse for more than a year without becoming pregnant?

Yes No

Are you nearing or over 35 and have had unprotected intercourse without for six (6) months without becoming pregnant?

Yes No

Do you have a history of pelvic infection or a sexually transmitted disease?

Yes No

Have you been treated with Clomid without becoming pregnant?

Yes No

Are you 38 y/o or older and contemplating a pregnancy in the future?

Yes No

Do you have a personal or family history of endometriosis and would like to get pregnant some day?

Yes No

Have you been diagnosed with a uterine abnormality or structural defect?

Yes No

Have you had two or more miscarriages or chemical pregnancies?

Yes No

Do you have a diagnosis of PCOS, PCOD or insulin resistance?

Yes No

Are your menstrual cycles irregular (that is longer than 35 days from start of one to start of next)?

Yes No

Have you been recently diagnosed with cancer or have a history of cancer in your family and would like to maintain reproductive potential?

Yes No

Do you have a family history of early menopause (occurring before age 45)?

Yes No

Have you been diagnosed with having uterine fibroids and would like to conceive in the future?

Yes No

Do you have especially heavy or painful menstrual periods?

Yes No

Do you have extra hair growth or acne or breast discharge without explanation?

Yes No

Have you been told you have “bad eggs” and would still like to have a baby?

Yes No

Has anyone told you that you are menopausal but you would still like to conceive?

Yes No

Do you or your husband have a family history of inherited birth defect or abnormality and you would like to have a child that does not have this problem?

Yes No

Are you or your male partner carriers of genetic mutations for cystic fibrosis, sickle cell, Thallasemia, Fragile X or other mutations that you do not want to pass along to your child?

Yes No

Male Questions:

Has your male partner had any type of testicular trauma, defect, or surgery?

Yes No

Has your male partner had problems with ejaculation, general infections, or erections?

Yes No