Medical And Personal Records

Gathering medical records early in the treatment process can save time, money and energy. A healthcare provider needs to know as much as possible about the health and reproductive background of his/her patients to offer appropriate treatment options

Patients may be annoyed because they have to repeat the same information they have shared with former doctors. Some of the questions may be uncomfortable to answer. They may ask about past occurrences that evoke feelings of shame or guilt. Remember that healthcare providers are not asking these questions to pass judgment but rather to look for any clues that might shed some light on the cause of the infertility.

Healthcare providers will be interested in the following history:

Gynaecological
  • Menstruation (age of onset, length and frequency of cycle, spotting between periods, heavy bleeding or cramping)
  • Sexual habits (frequency, problems with intercourse)
  • Sexual history
  • Contraceptive use (IUDs, birth control pills and other methods)
  • Sexually transmitted infections (STIs): chlamydia, gonorrhea, genital warts, syphilis
  • Pelvic surgeries or therapies (appendectomy, bowel repair, ovarian cyst removal, D&C, treatment for cervical dysplasia)
  • Pelvic infection, pelvic pain, feeling of heaviness in the abdomen
  • Abnormal PAP smears
  • Previous pregnancies and/or abortions
  • Fibroids (type, size and location)
  • Abnormal mammograms
  • Unusual hair growth

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Medical
  • Chronic medical conditions (diabetes, high blood pressure, asthma, arthritis, thyroid diseases and ulcers)
  • Cancer therapy
  • Chronic bladder or urinary tract infections (UTIs)
  • Medical or psychiatric drugs taken
  • Medication allergies

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Personal
  • Lifestyle and nutrition (diet, exercise, smoking, alcohol and recreational drug use)
  • Weight (recent weight loss or gain)
  • Exposure to environmental toxins (lead, radiation, pesticides, insecticides or PCBs)

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Family

Family history of:

  • Fertility-related problems
  • Recurrent miscarriages or difficult pregnancies
  • Mother's exposure to diethylstilbestrol (DES)
  • Mother's age at time of menopause
  • Sister's age at time of menopause
  • Genetic and chromosomal disorders (sickle cell anemia, Tay-Sachs disease, muscular dystrophy, hemophilia, Down syndrome, developmental disabilities, or cystic fibrosis)

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Previous Infertility Workups

When couples request their records, this information should be included:

  • Semen analysis (sperm count, motility, morphology, and any other sperm assessments)
  • Hormone studies (FSH, LH, TSH, estradiol, progesterone, testosterone, prolactin)
  • Pelvic or vaginal ultrasounds (a report of the findings)
  • Hysterosalpingogram (HSG): the report as well as the film taken during the procedure
  • Post-coital test (PCT)
  • Basal body temperature (BBT), cervical mucous observations and/or cultures
  • Endometrial biopsy
  • Laparoscopy (a report and existing photographs)
  • Hysteroscopy (a report and existing photoraphs)

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Previous Infertility Treatments
  • Ovulation induction cycles (name of stimulation medicine[s] and dosage, number of days taken, estradiol levels, number of follicles)
  • Intrauterine inseminations (IUIs): same information as above, as well as the day of cycle IUI was performed; semen-processing reports, including the percentage and grade of motile sperm
  • In vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) cycles (same information as above, as well as number of eggs retrieved, type of fertilization [standard IVF or ICSI], day of cycle when retrieved, number of embryos frozen, type of sedation received for retrieval, number and quality of embryos transferred, amount of time between cycles [rest cycles])
  • For certain sperm retrieval procedures such as testicular biopsies or a form of epididymal retrieval, your partner may have to request the results from his urologist

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Sample Medical Record Release Form

Most medical practices will not release medical records without written authorization. The following sample release form is all that is needed to have records sent to a current healthcare provider.

(Date)
Dear (Doctor):


This signed letter is written to authorize the release of my complete medical records to:
Doctor’s name:


Doctor’s address:
Doctor’s telephone number:


I would appreciate those records being sent by (date). If you have any questions, please call me at (Patient’s telephone number).

(Patient’s signature)
(Patient’s name, printed)
(Patient’s address)


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Tips

Before requesting medical records, couples should:

  • Call to determine to whom the authorization should be sent and at what fee, if any.
  • Keep a dated photocopy of the letter.
  • Call within seven to 10 days of sending the letter to verify the records have been released (ask for the name of the person to whom you should speak and record the outcome of the conversation).
  • Call the office to confirm that the records have arrived before an appointment with the fertility specialist.

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