Download Suspected infertility

Reproductive Medicine, Box 223
Cambridge University Hospitals NHS Foundation Trust
Referral Proforma: Suspected infertility
All investigations should be within 3 months of date of referral
Incomplete proformas may not be processed
Please enclose copies of all investigations, if performed out of Addenbrooke’s area
This is an:
NHS Referral
Self-funding Referral
Refer via Choose and Book
or to: Reproductive Medicine, Box 223
Hills Road, Cambridge CB2 0QQ
Refer to Cambridge IVF, Box 123
Hills Road, Cambridge CB2 0QQ
Tel: 01223 216227
Fax: 01223 586591
Tel: 01223 349010
Fax: 01223 726373
I am sending an accompanying letter
________________________________________________________________________________________________________________________________________________________________________
Referring GP's details for FEMALE patient (please print or stamp):
Name: Sender name.........................................
Surgery address: Sender organisation name
Surgery Fax: Sender fax ...................................
Sender address .......................................................
Referral date: Referral date ..............................
Please refer women who have been trying to become pregnant:


for more than two years if aged under 35 years
for more than one year if aged over 35 years
unless the cause is 'obvious' (i.e. irregular cycles, history of PID, suboptimal semen analysis)
History of infertility as a couple:
Primary
Secondary
......................................................................................................................................................... (duration)
Comments: .....................................................................................................................................................
........................................................................................................................................................................
FEMALE patient's details:
Surname: Surname.........................................
NHS No: NHS number .............................................
Forename: Forename .....................................
Hosp No: .................................................................
Age: Patient Age .............................................
Date of birth: Date of birth ........................................
Address: Patient address - single line ............
Home Tel: Patient home telephone number ............
Alternate Tel: Patient alternate telephone number
Mobile Tel: Patient mobile telephone number
Language of choice: ................................................
Communication/understanding difficulties
.....................................................................................................................................................
Page 1 of 3
Date: 05/04/2012
Version 2
File: in correspondence section of Medical Records
Three-page form
Reproductive Medicine, Box 223
Cambridge University Hospitals NHS Foundation Trust
Female patient's name: Forename Surname
Date of birth: Date of birth
________________________________________________________________________________________________________________________________________________________________________
Male partner details:
If there is a male partner, please ensure his details including GP contact details are completed (see last
page of this form) and sent with this proforma.
Details of a male partner are not required for this referred woman
FEMALE patient: (please attach copies of all results)
Female patient's name: Forename Surname .......................... Date of birth: Date of birth .............................
Parity: ....................................................................................................................................................... ......
Body Mass Index: ...................
History of PID
Date: ..............................
Endometriosis
If BMI is greater than 30, advise weight loss
Fibroids
Folic acid therapy started
Surgery etc to cervix:
........................................................................................................................................................................

Rubella status:
Rubella immune
Vaccination arranged
Normal
Abnormal
Date: ...............................

Cervical smear:
Date: ...............................

Chlamydia swab (endocervical/urethral):
Normal
Abnormal
Normal
Abnormal
Date: ...............................

High vaginal swab (HVS) (for vaginal infections):
Date: ...............................
 Serum progesterone (mid luteal 7 days before next expected period): ……………..nmol/L

Day 2-7:
LH ……………….........IU/L
FSH ……………………..IU/L
Date: ……………….........
Date: ……………….........
Only if progesterone is abnormal or patient is oligo/amenorrheic:
Testosterone: ................................. nmol/L
Prolactin: ........................ mU/L
TSH: .......................... mU/L
Date .........................................
Current medication: .........................................................................................................................................
.........................................................................................................................................................................
Comments: ......................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Page 2 of 3
Date: 05/04/2012
Version 2
File: in correspondence section of Medical Records
Three-page form
Reproductive Medicine, Box 223
Cambridge University Hospitals NHS Foundation Trust
Female patient's name: Forename Surname
Date of birth: Date of birth
___________________________________________________________________________________
MALE partner's details:
Surname: .................................................................
NHS No: ..................................................................
Forename: ...............................................................
Hosp No: ..................................................................
Date of birth: ............................................................
Age: .........................................................................
Address: ..........................................................................................................................................................
Home Tel: ................................................................
Work Tel: .................................................................
Mobile Tel: ...............................................................
Language of choice: ................................................
Communication/understanding difficulties
........................................................................................................................................................................
___________________________________________________________________________
Referring GP's details for MALE partner (please print or stamp):
Name: .............................................................................................................................................................
Surgery address: ............................................................................................................................................
Referral date: ...........................................................
Surgery Fax: ............................................................
____________________________________________________________________________________
MALE partner (please attach copies of all results):
Seminal fluid analysis:
Date of analysis ..............................................................................................................................................
Number sperm: .................................... /ml
% motility:.......................... %
% normal: ......................... %
............................................................................................................... (If abnormal, repeat after six weeks)
Past medical history: ........................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Clinical findings: ...............................................................................................................................................
.........................................................................................................................................................................
Current medications: ........................................................................................................................................
.........................................................................................................................................................................
.....................................................................................................................................................
____________________________________________________________________________________
Notes: please ensure that where there is a male partner all details are attached to the female partner's
information and sent to us together.
Page 3 of 3
Date: 05/04/2012
Version 2
File: in correspondence section of Medical Records
Three-page form