Name and family name*

Couple's age *

Your weight and height? *

How many years did you get married?*

How long have you been trying to get pregnant?*

Have you ever done an in vitro fertilization? several times? When? Please write the exact date.*

Have you done a semen analysis? Please send the report *

Have you had a varicocele problem? *

Have you ever had surgery? what was that? How many times? *

Do you have one of the common diseases (couples)? Diabetes - Blood pressure - Thyroid *

Are you currently taking a particular drug?*

Can you send the pictures and analysis that you have?*

.

.

Δ