Initial Diagnosis Treatment Plan Page1

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1 Initial Diagnosis Treatment Plan Page1 Age Gravidy and Parity Assessment: Primary infertility Secondary infertility Recurrent pregnancy loss Ovarian Factor Tubal factor Uterus factor advanced reproductive age diminshed ovarian reserve/abnormal CCCT polycystic ovary syndrome ovulatory dysfunction amenorrhea oligoovulation irregular cycles luteal phase defect low responder high responder Hx OHSS premature ovarian failure other right hydrosalpinx left hydrosalpinx bilateral hydrosalpinges right tubal occulsion left tubal occlusion s/p salpingectomy s/p BTL pelvic adhesive disease salpingitis isthmica nodosa Hx. salpinigitis/pid previous ectopic other: Asherman's syndrome endometrial polyp(s) fibroids-intracavitary fibroids-outside cavity fibroid(s) comment: proximal mid distal proximal mid distal bilateral right left cautery ring clip Pomeroy unsure type

2 Initial Diagnosis Treatment Plan Page2 Cervical factor Male factor Endometriosis Other Mullerian anomaly uterine agenesis cervical agenesis unicornuate uterus didelphic uterus bicornuate uterus septate uterus double uterus - evaluation in progress menorrhagia enlarged, consistent with adenomyosis in utero DES exposure other s/p LEEP s/p cone biopsy s/p cryotherapy poor mucous poor PCT incompetent cervix previous cerclage Hx cervical cancer other azoospermia CBAVD testicular failure oligospermia asthenospermia teratospermia Hx testicular cancer Hx testicular surgery Varicocele s/p varicocele repiar Vasectomy s/p vasectomy reversal other: right endometrioma left endometrioma pelvic adhesive disease other: hyperprolactinemia galactorrhea prolactinoma - RULE OUT minimal mild moderate severe bilateral right left

3 Initial Diagnosis Treatment Plan Page3 Oocyte Donor Candidate: hypothalamic amenorrhea s/p pituitary tumor dysmenorrhea dyspareunia vaginismus pelvic pain hypothyrodism hyperthyroidism thyroid disease hypertension Type I DM Type II DM Smoker Hx depression other: micro macro on bromocriptine on Dostinex s/p resection Never suicidal Previous suicide attempt Acceptable candidate - continue screening process Not an acceptable for oocyte donation Gestational Surrogate Candidate Acceptable candidate - continue screening process Not an acceptable for GC because Routine Pre-Conception Labs CBC Blood Type (ABO/Rh) Antibody Screen w/ reflex to ID TSH Prolactin (fasting) Glucose (fasting) Hep Bs Ag Hep C Ab HIV 1, 2 HTLV I/II RPR Rubella Titer (IgG) Varicella Titer (IgG) Cystic Fibrosis Screen Day #3 FSH/E2 CCCT Labs (Cervix) Pap smear Gonorrhea Chlamydia Routine aerobic Mycoplasma/Ureaplasma Labs (Pre-IVF)

4 Initial Diagnosis Treatment Plan Page4 Own Eggs Recipient/Oocyte Donation CCCT UA/C&S, if indicated LAC APA panel CMV IgG, IgM LAC APA Panel ALT/AST CMV IgG, IgM yo: 45+ yo: Labs (Metabolic/PCOS/hirsutism) Labs (RPL) Fasting Glucose and Insulin Hb A1C Fasting Lipid Profile 3-hr OGTT ALT AST Creatinine Testosterone, total Testosterone, free DHEAS 17-OHP 24-hr urinary free cortisol s/p Bariatric Surgery Baseline Labs CBC Iron Studies serum albumin folic acid level vitamin B12 level calcium phosphorous 25-hydroxy vitamin D level APAS panel LAC Protein C activity Protein S activity AT III Factor II activity (prothrombin 20210A mutation) Factor V Leiden Factor VIII activity MTHFR Mammogram Mammogram ECG Chest X-ray Iron level TIBC Ferritin

5 Initial Diagnosis Treatment Plan Page5 Homocysteine level PAI-I Karyotype other Imaging studies HSG Water sonogram HSC Chest X-ray Mammogram Pelvic ultraound MRI pelvis MRI pituitary Labs (Genetic) Karyotype Female CF Jewish Genetic Hgb Electrophoresis Labs (Thyroid) Labs (other) TSH free T4 Triiodothyronine (T3) Anti-thyroid antibodies beta-hcg E2 LH ASAb - serum calcium - serum phosphorous - serum cortisol - 8 AM ALT (SGPT) AST (SGOT) creatinine Hepatits panel LFTs CA-125 progesterone other Labs (Male) NCFMC anywhere Antisperm antibodies Check Morphology w/ 1st IUI Tay Sach's Gaucher's Canavan's Familial dysautonomia Antithyroglobulin Anti-TPO antibodies Thyroid stimulating Immunoglobulin (TSI)

6 Initial Diagnosis Treatment Plan Page6 Overnight Sperm survival assay CF, carrier screen CF, Ambry STD panel Semen cultures karyotype Y-microdeletion CBC Hgb electrophoresis Jewish Genetic Tay Sach's Gaucher's Canavan's Familial dysautonomia SCSA other Surgical Procedures Laparoscopy Hysteroscopy D&C Laparotomy Tubal anastomosis Donor Sperm Insemination Brochure Given Discussed with lysis of adhesions with fulguration of endometriosis with excision of endometrioma with ovarian cystectomy with bilateral tubal occlusion with unilateral tubal occlusion: with bilateral salpingectomy with unilateral salpingectomy with bilateral neosalpingostomy with unilateral neosalpingostomy with uterine suspension with chromotubation diagnostic with polypectomy with lysis of adhesions with myomectomy with tubal catheterization with polypectomy with suction for missed abortion with karyotype for POC with myomectomy with lysis of adhesions with removal of endometriosis with neosalpingostomy: with fimbrioplasty: sperm banking and donor selection HIV screening and risks

7 Initial Diagnosis Treatment Plan Page7 OVULATION INDUCTION CC/IUI Discussed Discussed GONADOTROPIN/IUI IVF Discussed Discussed Oocyte Donor Candidate use of ovarian stimulation and medication options cycle monitoring techniques timing of insemination success rates treatment specifics medication options ovulation success rate pregnancy success rate multiple gestations ovarian cancer risk from medications cycle cancelation criteria IVF/OD procedure discussed in detail Potential Risks reviewed See signed Consent allergic reaction OHSS treatment specifics multiple gestations ovarian cancer risk from medications cycle cancelation criteria success rates Endometriosis may worsen with time. Fertility therapy may hasten endometri treatment specifics risk of multiple gestation about 25 percent, and complications associated with ovarian cancer risk from medications cycle cancelation criteria success rates option and risk of selective reduction Endometriosis may worsen with time. Fertility therapy may hasten endometri treatment specifics success rate factors success rates number of embryos to transfer (twins, approximately 40 percent and triplets, or more, less than 5 percent) unknown ovarian cancer risk from medications ICSI, risk of birth defects with ICSI Assisted Hatching cryopreservation of embryos and FET option and risk of selective reduction MicrSort for sex selection is imperfect PGD for sex selection is not offered at NCFMC, but is offered elswhere Endometriosis may worsen with time. Fertility therapy may hasten endometri

8 Initial Diagnosis Treatment Plan Page8 bleeding infection requiring hospitalization or surgery pelvic adhesions (scar tissue) future unknow risks, such ovarian tumors or cancer Disclosure of oocyte(s) and embryo(s) disposition reviewed See signed Disclosure Form one or two recipients per cycle recipients may be heterosexual, homosexual or single pregnancy results are anonymous embryo disposition is determined by recipient(s) only Comment: IVF OOCYTE DONATION/Recipient Discussed Treatment specifics success rate factors success rates number of embryos to transfer (twins, approximately 40 percent and triplets, or more, less than 5 percent) ICSI Assisted Hatching cycle cancelation criteria option and risk of selective reduction MicroSort sperm selction is imperfect PGD for sex selection is not offered at NCFMC, but is offered elswhere Gestational Surrogate Candidate Discussed Psychological Evaluation Schedule psycological evaluation Attend IVF Orientation class Schedule with nursing staff Attend Injection Training Class Schedule with nursing staff Smoking cessation recommended Patient Partner Both partners Consults Primary care Andrology - Dr Opsahl Andrology - Urologist Treatment specifics success rate factors success rates number of embryos to transfer (twins, approximately 40 percent and triplets, or more, less than 5 percent) cycle cancelation criteria option and risk of selective reduction Screening procedures, including hysteroscopy screening partner mandatory legal contract

9 Initial Diagnosis Treatment Plan Page9 Andrology - Endocrinologist Teaching Info Sheets Hysterosonogram HSG AH ICSI NSA Blastocyst Embryo cryopreservation Donor egg Donor sperm IUI

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