FertNetwork IVM Questionnaire

About you

What is your legal first name? *

And your legal last name? *

What is your date of birth? *

Which state do you live in? *

Care is governed by the state you live in. This tells us whether we can see you now or should add you to our waitlist for your state.

What email address should we use? *

What is the best mobile number for you? *

Do you currently have ovaries? *

YesNoNot sure

How tall are you? Feet and inches or centimeters is fine. *

And your current weight? Pounds or kilograms. *

Your goals

What are you hoping to do right now? *

Becoming pregnant nowCreating and freezing embryosFreezing eggsFertility preservation before medical treatmentLearning about my optionsOther

Will you need any of these? You can pick more than one. *

Partner spermDonor spermDonor eggsGestational carrierNot sure

What is drawing you to IVM? Pick anything that applies. *

I want fewer hormone injectionsI am afraid of needlesI cannot attend frequent monitoring appointmentsMy work or family schedule is very busyI previously had significant side effects from fertility medicationI have PCOS or a high ovarian reserveI am concerned about ovarian hyperstimulation syndromeMy fallopian tubes are blocked or damagedMy partner has a low sperm count or another sperm problemI need donor spermI need genetic testing of embryosConventional IVF did not work for meMy doctor recommended IVMOther

Travel and treatment plan

Your egg retrieval takes place at the New Hope Fertility Center laboratory in New York City. Would you be able to travel to New York for it? *

YesYes, with some planningI live in or near New YorkNoNot sure

Most of your care happens from home. The retrieval is the one step that happens in person, in New York.

Some people need more than one retrieval to create enough embryos. If your physician recommends it, would a second trip to New York be possible? *

YesMaybeNo

With IVM, every embryo is frozen first and transferred in a later cycle, not during the same trip. Does that timing work for you? *

YesI would like to learn more about itNo, I want a fresh transfer

Freezing every embryo lets the lab finish maturing and growing them, and lets your body reset before the transfer.

When the time comes, where would you prefer to have your embryo transfer? *

In New YorkAt a partner clinic closer to homeNot sure yet

We sometimes run approved research studies on IVM. Would you like our team to let you know about any you may be able to join? It is completely optional and does not affect your care.

YesNo

Pregnancy history

Are you currently pregnant, or is there a chance you might be? *

NoYesNot sure

How long have you been trying to become pregnant? *

Not currently tryingLess than 6 months6 to 11 months12 to 23 monthsTwo years or longer

Have you ever been pregnant? *

NoYes

How many miscarriages have you had?

How many living children do you have?

Are you currently breastfeeding? *

NoYes

Periods and ovaries

How often do your periods usually come? *

Have you been diagnosed with any of these? *

PCOS or polycystic ovariesDiminished ovarian reservePremature ovarian insufficiencyEndometriosisOvarian cystsUterine fibroidsUterine polypsAdenomyosisBlocked or damaged fallopian tubesHydrosalpinxNoneNot sure

Have you had an ovary removed? *

NoOne ovaryBoth ovariesNot sure

Have you had surgery on either ovary? *

NoYesNot sure

What kind of surgery was it, and roughly when?

Have you had chemotherapy or pelvic radiation? *

NoYesTreatment is planned soon

Tests you have had

Have you had an AMH blood test done? *

YesNoNot sure

AMH is a blood test that estimates your egg supply. If you have not had it, that is completely fine. We can help you arrange it near home.

Do you know your AMH result? Please include the units if you have them.

Enter the number and choose the unit shown on your report, ng/mL or pmol/L.

Have you had a baseline ultrasound where they counted your follicles? *

YesNoNot sure

Also called an antral follicle count. If you have not had one, that is fine. We can help you arrange it near home.

How many follicles were counted on your right ovary?

And on the left ovary?

Have your fallopian tubes been checked, for example with an HSG? What did it show?

If you have AMH, ultrasound or other lab reports, you can upload them here.

Previous treatment

Have you had any fertility treatment before? Pick all that apply. *

NoTimed intercourseIUIConventional IVFMinimal-stimulation IVFNatural-cycle IVFIVMEgg freezingOther

Having had IVF before does not rule you out. It simply helps the physician understand your history.

Roughly how many eggs were retrieved in your most recent cycle?

Did any of these happen during previous treatment?

Ovarian hyperstimulation syndromeVery high response to fertility medicationPoor response or few eggsLow egg maturityFertilization failureNo blastocyst developmentSignificant medication side effectsCycle cancellationNone

If you have records from previous cycles, you can upload them here.

Sperm source

What sperm source do you expect to use? *

Male partnerKnown donorSperm bank donorPreviously frozen spermSurgical sperm retrievalNot decided

Has a semen analysis been done?

Health history

Do you have any of these conditions? *

DiabetesHigh blood pressureHeart diseaseBlood-clotting disorder or previous blood clotKidney diseaseLiver diseaseThyroid disorderSeizure disorderAutoimmune diseaseCancerSignificant psychiatric conditionNone

Are those well controlled with treatment right now?

Yes, all are well controlledSome are not well controlledNoNot sure

Is the cancer currently active or under treatment?

Yes, active or currently in treatmentNo, in remission or completed treatmentNot sure

Have you ever had a serious reaction to anesthesia or sedation? *

NoYesNot sure

Are you taking any blood thinners? *

NoYesNot sure

Do you have any medication allergies? *

NoYes

Which medications are you allergic to?

What medications and supplements are you taking currently?

Do you currently use any of these? *

Cigarettes or nicotineMarijuanaRecreational drugsMore than seven alcoholic drinks per weekNone

Anything else

Are you experiencing any of these right now? *

Heavy vaginal bleedingSevere pelvic painFever with pelvic painA current or recent pelvic infectionNone of these

Is there a deadline by which your treatment needs to start? *

No specific deadlineWithin the next few weeksWithin the next few monthsNot sure

Anything else you would like the clinical team to know?

I understand this questionnaire helps the FertNetwork team prepare for my consultation. It does not confirm that IVM is right for me. A physician makes that decision with me. *

I agree

This form is not monitored for urgent medical concerns. If you have a medical emergency, call 911 or go to the nearest emergency department.

By checking this box, you agree to receive text messages from FertNetwork at the phone number provided, including messages about your inquiry, scheduling, and appointment reminders. Consent is not a condition of purchase or of receiving care. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. See our Privacy Policy.

Please agree to receive text messages to continue.

Your answers go only to the New Hope Fertility Center clinical team. Most people finish in about 10 minutes.

About you

Your goals

Travel and treatment plan

Pregnancy history

Periods and ovaries

Tests you have had

Previous treatment

Sperm source

Health history

Anything else

Thank you