High Tech Survey #1105

1. Attempt:
   Sex: Girl Boy Sperm Sorting: MicroSort Ericsson Other Sperm Sorting None (PGD Only) PGD: Yes No
2. Cycle Type: Artificial Insemination: IUI, ICI, or IVI IVF (or GIFT/ZIFT/TET) FET (Frozen Embryo Transfer)
3. Attempt #: 1 2 3 4 5 6 7 8 9 10 11 12
4. Cycle Date:    
5. Fertility Clinic:

   Clinic Name:
   Clinic City:
   U.S. State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
   Country:

6. Why did you want to use gender selection?
   Family balancing or preference Medical need

   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? No Egg Donor Sperm Donor Donated Embryo

About You

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

   Pregnancies: 0 1 2 3 4 5 6 7 8 9 10 11 12+  Live Births: 0 1 2 3 4 5 6 7 8 9 10 11 12+

3. Genders of your current children:
   Boys: 0 1 2 3 4 5 6 7 8 9 10 11 12+  Girls: 0 1 2 3 4 5 6 7 8 9 10 11 12+
4. Previously, how easily did you become pregnant? Very easily, got pregnant on first or second try Fairly easily, took just a few tries Took quite a few tries, but managed it Took a long time Required IUI or IVF to get pregnant previously
5. If a semen analysis was performed, what were the results?

   Overall	Count	Morphology	Motility	Progression	pH
   Excellent Very Good Average Fair Poor		%	%	0 (None) 1 1+ 2 2+ 3- 3 4 (Fast!)
   	Million per mL	% Normal	% Moving	Speed

6. Where do you live?

   U.S. State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming or Other Country:

Artificial Insemination (IUI/ICI/IVI)

1. Insemination Type: IUI (Intra-Uterine Insemination) ICI (Intra-Cervical Insemination) IVI (Intra-Vaginal Insemination) Unknown
2. Fertility Drugs: None - Natural Cycle Clomid Only Combo - Clomid + Injectibles Injectibles Unknown

   Comments:
   

3. Ovulation Monitoring:
   Self-Monitoring with OPKs (ovulation prediction kits) OPKs plus 1 or 2 days of clinic monitoring Full monitoring Outside monitoring Unknown
4. Number of mature follicles at time of insemination:
   Total:     Ruptured:  

MicroSort

1. Sort Percentage: %  
2. Which MicroSort facility performed your sort?
   GIVF in Fairfax, VA HRC in Laguna Hills, CA
3. Did you use fresh or frozen sperm?
   Fresh (Never frozen) Frozen once (after MicroSorting) Frozen twice (before and after MicroSorting)
4. Sperm Count:

   Pre-Sort:	Million
   Post-Sort:
   Post-Thaw:	(If frozen)

5. Did you get an extra vial? Yes
6. Other comments about MicroSort:
   

Expenses and Travel

Expense Totals

Expense Details

Other comments about expenses and travel:

Cycle Outcome

1. Cycle Result: In Progress Waiting for Pregnancy Test (2ww) Positive Pregnancy Test No Pregnancy No Transfer Cancelled Cycle (No Answer)
2. Beta Results:
   
3. Other Comments: