Consult :.

     TIPS to fill the form:

  • Take printout and fill it first offline. Get your doctor help for full information.

  • All information supplied here is confidential as it will be answered by Dr. Anoop Gupta himself.
Your Name               Name of Husband 
Email Address    Please ensure that this is a valid email address. We only reply by Mail.
Country/City of residence?          
How long have you been married?
Have you ever conceived?  
How long you are seeing a infertility Specialist ? 
Do you know specific reason of not getting pregnant?

FEMALE HISTORY

Age    Birthdate     Height ( ft )     Weight ( kg) 

Menstrual periods occur every days.  
For how many days do you bleed ?
Have you been told you have endometriosis/PCOD ?
Have you ever had pelvic inflammatory disease (PID) ?
Any pregnancies or miscarriage? How may days/weeks and when
Any D&C for any reason?
Any History of delayed Period?
Bleeding reduced over a period of time?
Any History of ectopic pregnancy?
Any History of Pelvic Surgery?
Any current medication?
Any Other problems?

MALE HISTORY

Age    Birthdate Wt :    Ht :

Any pregnancies. Which year ?
Do you have any sexual problems
OR any medical problem?
Sperm count: million per ml.     Motility %      Morphology :
Any current medication?
   
MEDICAL TESTS Yes / No Date Result
Hysterosalpingogram
 ( X-ray of the uterus and tubes)		 Yes   No
Laparoscopy Yes   No
Hysteroscopy Yes   No
Hormonal blood tests. Yes   No
FSH Yes   No
LH Yes   No
Prolactin Yes   No
TSH Yes   No
Other Yes   No
     
MEDICAL TREATMENT Yes / No How Many Date Any Success

Ultrasound monitoring

 Yes   No

(IUI) without any stimulation

 Yes   No

(IUI) with any stimulation (CC/HMG)

 Yes   No

In vitro fertilization (IVF)

 Yes   No

IVF-ICSI

 Yes   No

Assisted Hatching

   Yes   No
Give details of IVF / ICSI results, if applicable.  
Stimulation protocol used No. Of eggs retrieved Embryos formed Embryos transferred Embryos frozen
Quality of Embryos : The day of transfer : 

Any  Specific problems?

 Your  Specific query?

Convenient Time to consult the doctor on phone:

IST 6:00 to 7:00PM

at : 91-9811081024, 9810600234