Second Opinion Form

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Dr. Rajeev Agarwal

Laparoscopic Surgeon & Clinical Director, Care IVF, KOLKATA

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Condom Oral Pills Copper T
General Gynecologist Infertility Specialist
Male Factor Infertility
Azoospermia
Tubal Factors
Low Sperm Count
Endometriosis
Poor Ovarian Reserve
PCOS
Unexplained Infertility
Don't Know

Female History




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Pregnancy History


Sl No Year Mode of Conception Fate Remarks

IUI History


IVF History


Sl No Year Location Doctor Stimulation Drugs No Of Oocytes Recovered No Of Embryo Stages

Embryo Transfer History


Sl No Year Location Doctor Fresh (Number and Grade) Frozen (Number and Grade) Assisted Hatching (Yes / No)
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Recent Reports (Fill only the ones relevant to you)


Test Date (MM/YY) Value
HB
HPLC
PPBS
HBSAG
TSH
PRL
D-TOTAL CA125
ANTI THYROGLUBIN ANTIBODY
LUPUS
Anti-Cardiolipin Antibody
Anti-Phospholipid Antibody
KARYOTYPING
AMH (Anti Mullerian Hormone)
If you have any other relevant reports, please send as an attachment. Yes No

Please click a picture or scan and attach reports of the following investigations (if relevant in your case). For Hysteroscopy and Laparoscopy kindly attach the videos for the same as well:



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Male History


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Semen Analysis Report


Date
Enter Date
Sperm Count
Motility
Morphology
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