Date:
Patient:
MRN:
Clinician: (Reproductive Endocrinologist, Oncologist, Urologist)
Reason for Visit:
Consultation for fertility preservation
Evaluation of underlying condition requiring fertility preservation (medical diagnosis, planned treatment)
Discussion of fertility preservation options
Review of risks and benefits of each option
History of Present Illness:
Briefly describe the underlying medical condition or planned treatment that necessitates fertility preservation.
Document the patient’s age and desire for future biological children.
Include any relevant menstrual history (regularity, cycle length).
Past Medical History:
Include any past medical conditions that may affect fertility or the chosen preservation method (e.g., pelvic inflammatory disease, prior surgery).
History of sexually transmitted infections (STIs).
Family History:
Family history of genetic conditions (if applicable).
Social History:
Partner status (single, seeking sperm/egg donation)
Smoking history (can impact egg quality).
Physical Exam:
General: Vital signs (temperature, blood pressure)
Pelvic exam (if indicated) – to assess pelvic anatomy and potential risk factors for egg retrieval.
Labs:
Consider mentioning specific labs ordered based on the patient’s age and chosen preservation method:
Hormonal profile (FSH, LH, estradiol) – to assess ovarian reserve
Anti-Müllerian hormone (AMH) – another marker of ovarian reserve
Karyotype testing (chromosome analysis) – may be recommended in specific cases
Imaging:
Pelvic ultrasound – to assess antral follicle count (AFC) as a marker of ovarian reserve.
Assessment:
Confirm the need for fertility preservation based on the underlying medical condition or planned treatment.
Evaluate ovarian reserve to determine the most suitable preservation method.
Discuss the patient’s reproductive goals and preferences.
Plan:
Outline the recommended fertility preservation option(s):
Ovarian cryopreservation: Egg retrieval and freezing for later use in in vitro fertilization (IVF).
Embryo cryopreservation: Fertilization of eggs with sperm (partner or donor) followed by embryo freezing.
Oocyte vitrification: A newer freezing technique for eggs, potentially improving success rates.
Ovarian tissue cryopreservation: Removal and freezing of ovarian tissue for future use in in vitro maturation (IVM) of eggs (experimental technique).
Sperm cryopreservation: Collection and freezing of sperm for later use in insemination or IVF.
Risks and Benefits:
Discuss the specific risks and benefits of each fertility preservation option considering the patient’s age and medical condition.
Address potential complications of ovarian stimulation medications used for egg retrieval.
Review success rates and limitations of each method.
Next Steps:
Depending on the chosen method:
Schedule further testing or consultations (e.g., sperm banking for egg freezing).
Initiate ovarian stimulation medications in preparation for egg retrieval (if applicable).
Discuss financial implications of fertility preservation procedures.
Education:
Document any education provided to the patient regarding:
The impact of the underlying condition or treatment on fertility
The different fertility preservation options available
The success rates and limitations of each method
The importance of timely decision-making for optimal preservation results
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the options and any emotional concerns they may have.
Document the patient’s preferred course of action.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a qualified healthcare professional specializing in fertility preservation for diagnosis, treatment recommendations, and personalized guidance.