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High Tech Survey #1268

Username: regyny
Boy Attempt #1: Other/IUI in December 2010

  1. Attempt:
    Sex: Sperm Sorting: PGD:
  2. Cycle Type:
  3. Attempt #:
  4. Cycle Date:    
  5. Fertility Clinic:
    Clinic Name:
    Clinic City:
    U.S. State:
    Country:
  6. Why did you want to use gender selection?

    If using for a medical need, such as to avoid a
    sex-linked genetic disorder, please describe:

  7. Are you or your spouse infertile or sterile? Yes
  8. Did you use an egg or sperm donor?

About You

  1. Mother's Age:       Father's Age:    
  2. Number of previous pregnancies and births:

    Pregnancies:  Live Births:

  3. Genders of your current children:
    Boys:  Girls:
  4. Previously, how easily did you become pregnant?
  5. If a semen analysis was performed, what were the results?
    OverallCount    Morphology     Motility   ProgressionpH
    % %
     Million per mL % Normal % Moving Speed
  6. Where do you live?

    U.S. State: or Other Country:

Artificial Insemination (IUI/ICI/IVI)

  1. Insemination Type:
  2. Fertility Drugs:

    Comments:

  3. Ovulation Monitoring:
  4. Number of mature follicles at time of insemination:
    Total:     Ruptured:  

Expenses and Travel

Expense Totals

$Multi-Cycle Package Total 

Number of cycles in package:  

$Cycle Total  
$Travel Total  
Number of nights: - Mom   - Dad  
Did you travel to another country? Yes

Expense Details

$Sperm Sorting or Sperm Separation
$PGD  
$Preliminary Testing and Consultation  
$Fertility Drugs  
$Sperm Cryopreservation  
$Embryo Crypreservation  
$Artificial Insemination (IUI/ICI/IVI)  
$IVF (or GIFT/ZIFT/TET)  

Other comments about expenses and travel:

Cycle Outcome

  1. Cycle Result:
  2. Beta Results:
  3. Other Comments:

Pregnancy

  1. Due Date: (or Birth Date) 
  2. Number of Babies Conceived:
    Choose the total number of sacs or babies ever observed by ultrasound, even if not all survived.
  3. If you conceived multiples, type of multiples:
  4. Pregnancy Problems:
    If you experienced any problems in this pregnancy (mother or baby) please describe:

Baby

  1. Sex:     Currently:
  2. CVS, amnio, or other genetic analysis results:

    If abnormal, please describe: