Female infertility

{Female infertility}

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

HISTORY
Fertility history: 
  Previous conceptions: G:0, P:0, M:0, T:0.
  Period of infertility (time trying to conceive): 
  Frequency of intercourse: 
  Libido:

Menstrual history:
[-] cycle < 23-35 days (normal)
[-] cycle < 23 days days
[-] cycle > 35 days
[-] irregular
[-] ovulatory symptoms (breast tenderness, ovulatory pain, bloating)
[-] dysmenorrhoea

Gynaecological history:
[-] dysmenorrhoea 
[-] dyspareunia 
[-] PID 
[-] pelvic pain
[-] PCOS
[-] endometriosis 
[-] STIs
[-] abnormal cervical screening
[-] cervical carcinogenesis
[-] gynaecological surgery/procedures
Details: 
-

Endocrine history:
[-] thyroid disease 
[-] galactorrhoea 
[-] hirsutism 
[-] acne 
[-] male pattern baldness

Family history:
[-] infertility 
[-] birth defects 
[-] known genetic mutations 
Details: 
-

Occupational History:
-

Personal history:
[-] smoking 
[-] alcohol use

Partner Medical History:
[?] infertility
[?] oligospermia 
[?] azospermia
Details: 
-

PHYSICAL EXAMINATION
General Examination:
  Height (m): 
  Weight (kg): 
  BMI (weight/height^2):

[-] acne
[-] hirsutism
[-] male pattern baldness

PV examination:
[-] vaginal abnormalities 
[-] uterine enlargement 
[-] other uterine abnormality 
[-] adnexal mass 
[-] adnexal tenderness 
[-] tender nodules

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Diagnostic investigations requested:
[+] Day 2 of cycle LH, FSH, Oestradiol (E2), Prolactin, TSH 
[+] Anti-mullerian hormone (AMH) 
[+] FBC
[+] Blood group and antibodies
[+] Serology (HCAb, HBsAg, HBsAb, HIV Ab/Ag, Syphilis Ab, VZV Ab, Rubella Ab)
[+] Swabs for Chlamydia/Gonorrhoea
[\] Pelvic ultrasound (long cycle, PCOS?)

[\] Patient basal temperature charting

Treatment:
-

Patient information and advice:

Referrals: 
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

Notes

Considerations for early referral:

age >35 years
oligomenorrhoea
prior pelvic surgery
previous STI/PID
abnormal pelvic examination
low AMH
doctor or patient concerns

Female infertility

Notes

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