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Domestic partnership How long have you been seeking pregnancy: COUPLE’S INFORMATION :::: SHE :::: Age Weight Hight cm. Region of Residence—Seleziona un'opzione—AbruzzoBasilicataCalabriaCampaniaEmilia-RomagnaFriuli-Venezia GiuliaLazioLiguriaLombardiaMarcheMolisePiemontePugliaSardegnaSiciliaToscanaTrentino-Alto AdigeUmbriaValle d’AostaVenetoOther
:::: HE :::: Age Weight Hight cm. Region of Residence—Seleziona un'opzione—AbruzzoBasilicataCalabriaCampaniaEmilia-RomagnaFriuli-Venezia GiuliaLazioLiguriaLombardiaMarcheMolisePiemontePugliaSardegnaSiciliaToscanaTrentino-Alto AdigeUmbriaValle d’AostaVenetoOther
:::: LEI :::: If you have done a hysterosalpingography, indicate the result—Seleziona un'opzione—OpenClosedDoubtful results If you performed ultrasound monitoring of spontaneous ovulation (i.e. without ovulation stimulating drugs), indicate the result:—Seleziona un'opzione—RegularIrregularNo ovulation If you have measured a dosage on the 2nd or 3rd day of the hormone cycle of of the FSH, LH, 17 beta estradiol and prolactin, please indicate the result: FSH MUI/ML LH MUI/ML 17 Beta Estradiol PG/ML Prolactin NG/ML AMH (anti-Mullerian hormone) Brief notes on menstrual history Any further information:
:::: LUI :::: If you have done one or more spermiograms tests: Number Million/ML Motility percentage Percentage in conformity with norms: Difficulty to have an intercourseYesNo Intercourse frequency:—Seleziona un'opzione—1-2 per settimana1-2 per mese Any further information: Your e-mail address, please:
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