Welcome to pgt.clinic

We appreciate that it can be difficult to seek information about your fertility journey. Our goal is to provide you with a structured approach to understanding your fertility needs.

We believe in assessing every case from the DNA up: starting with the genetic factors that might influence your fertility, and moving through your health profile to create a personalised plan that suits your goals and values.

🔒 Your privacy matters.
We will not ask for personal details in the initial stages. Feel free to work through this assessment with your GP, specialist, or fertility doctor.

Getting Started

Let's start with the basics

Tell us a little about you and your situation.

👤 About You

Your age

Do you have a partner?

Yes No

Partner's age

🥚 Egg Source

Will you be using your own eggs?

Yes No — I am planning to use donor eggs

Age of the egg donor

Other information about the egg donor

🧬 Sperm Source

Will your partner be providing sperm?

Yes No — I am planning to use donor sperm

Age of the sperm donor

Other information about the sperm donor

🗺️ Fertility Journey Stage

Where are you in your fertility journey?

Just thinking about pregnancy and wanting to plan ahead Trying to get pregnant, but taking longer than expected Considering IVF with genetic testing of embryos

Section A — Planning Pregnancy

Genetic History

Let's understand your genetic background and any relevant family history.

🧬 Family Genetic History

Do you have a personal or family history of a genetic condition?

Yes No

Which condition(s)?

When were they diagnosed?

Is there a genetic test report available?

Yes No

Is there DNA available?

Yes No

🔬 Carrier Screening

Have you had reproductive genetic carrier screening?

Yes No

Which type of screening?

Three condition (CF, SMA, Fragile X) Expanded carrier screening — individual Expanded carrier screening — couple

Results

🔎 Karyotype Testing

Have you had karyotype testing (chromosome analysis)?

You

Yes No

Result

Your partner

Yes No

Result

Gynaecological History

Your Menstrual & Gynaecological Health

This section helps us understand your reproductive health profile.

📅 Menstrual Cycle

Last menstrual period

Days of bleeding per cycle

Days between periods

Bleeding between periods?

Yes No

Details

Menstrual cycle regularity

Regular (predictable timing each month) Irregular (unpredictable timing) Not sure (e.g. using contraception)

Signs of high androgens?

Acne Hirsutism (unwanted hair growth) Voice changes Hair loss None

Signs of high prolactin?

Galactorrhoea (breast milk production when not pregnant) Visual changes None

Signs of hypothyroidism?

Fatigue / low energy Unexplained weight gain Feeling cold easily Constipation Dry skin / hair Heavy or irregular periods None

Signs of hyperthyroidism?

Anxiety / nervousness Unexplained weight loss Feeling hot / excessive sweating Rapid or irregular heartbeat Trembling hands Light or absent periods None

🩺 Gynaecological Conditions

Have you ever been diagnosed with a sexually transmitted infection?

Yes No

Which infection(s) and when?

Do you experience severe pelvic pain with your periods?

Pain severe enough to miss work/school Pain requiring strong pain medication Pain interfering with daily activities No

Do you have very heavy periods?

Soaking through protection Passing large clots Bleeding lasting more than 7 days No

Pain with intercourse (deep pain)?

Yes No

Bowel symptoms, especially around your period?

Painful bowel movements Cyclic diarrhoea or constipation Rectal bleeding during periods No

Ever diagnosed with endometriosis or adenomyosis?

Yes No

When and how was it diagnosed?

🛡️ Cervical Screening & Contraception

Are you up to date with cervical screening tests?

Yes No

Ever had an abnormal CST?

Yes No

Details

Currently using contraception?

Yes No

Which type?

Which types have you used in the past?

Pregnancy History

Previous Pregnancies

Please tell us about any previous pregnancies you've had.

🤰 Pregnancy History

Have you been pregnant before?

Yes No

How many times have you been pregnant?

How many living children do you have?

When were they born?

Significant issues during pregnancy or childhood?

Have you had any pregnancy losses?

Biochemical pregnancy (very early loss) Miscarriage (loss before 20 weeks) Stillbirth (loss after 20 weeks) Termination Ectopic pregnancy

For any losses, was genetic testing performed?

Yes No

Details

🧪 Autoimmune Conditions

Have you been diagnosed with any autoimmune conditions?

Systemic lupus erythematosus (SLE) Antiphospholipid syndrome Other autoimmune conditions None

Details

Have you had antiphospholipid antibody testing?

Yes No

Results

Maternal Health

Health & Nutrition

Factors that can influence pregnancy outcomes.

💊 Medical History

Do you have any medical conditions?

Yes No

Details

Are you currently on any medications (including supplements)?

Yes No

Which medications?

Are you taking a preconception multivitamin?

Yes No

Which type?

Risk factors for 5mg folic acid supplementation?

Personal or family history of neural tube defects BMI over 30 Conditions affecting nutrient absorption (IBD, coeliac, etc.) Medications that interfere with folic acid No

📏 Anthropometrics & Lifestyle

Your weight (kg)

Your height (cm)

Do you drink alcohol?

Yes No

Standard drinks per week

Do you smoke cigarettes?

Yes No

Packs per day

Years smoking

Do you use recreational drugs?

Yes No

Which types and when?

Partner Health

Your Partner's Health

These questions help us assess any male factor considerations.

👨 Partner Reproductive History

Has your partner had previous pregnancies (with you or others)?

Yes, in this relationship Yes, in previous relationships No

Conditions affecting testicular function?

Previous testicular surgery Trauma to testicles Mumps orchitis or testicular infection Undescended testes Chemotherapy or radiation Varicocele None

Any issues with sexual function?

Erectile dysfunction Premature ejaculation Delayed or absent ejaculation Pain with intercourse None

💊 Partner Medical & Lifestyle

Does your partner have any medical conditions?

Yes No

Details

Does your partner take any regular medications?

Yes No

Details

Partner's weight (kg)

Partner's height (cm)

Does your partner drink alcohol?

Yes No

Standard drinks per week

Does your partner smoke?

Yes No

Packs per day

Years smoking

Does your partner use recreational drugs?

Yes No

Which types and when?

Section B — Trying to Conceive

Conception Attempts

Let's understand your experience trying to conceive.

⏱️ Duration & Approach

How long have you been trying to conceive? (months)

Managing regular unprotected sex around ovulation?

Yes No

Difficulty timing due to anovulation Sexual dysfunction Difficulty due to timing (e.g. FIFO)

🔍 Infertility Diagnosis

Have you been diagnosed with infertility?

Male factor Tubal factor Endometriosis Anovulatory Other

Details

🏥 Previous IVF

Have you had IVF in the past?

Yes No

How many egg retrieval procedures?

Eggs collected in last retrieval?

Total embryos in storage

Embryos suitable for transfer

Protocol used (antagonist, agonist, etc.)?

Starting dose and type of FSH

Any complications?

Section C — IVF & PGT

Genetic Testing of Embryos

Please tell us why you are considering preimplantation genetic testing.

🧬 Reason for PGT

Why are you considering genetic testing of embryos?

Single gene condition (PGT-M) Chromosome rearrangement (PGT-SR) Age-related pregnancy loss (PGT-A)

🎯 PGT-M Details

Condition

Gene

Variant(s)

Where was genetic testing performed?

Genetic report available?

Yes No

DNA available?

Yes No

Mode of inheritance

Background

References (family members for workup)

Reference 1

Reference 2

🔀 PGT-SR Details

Type of chromosome rearrangement

Reciprocal translocation Robertsonian translocation Pericentric inversion Paracentric inversion Other

Details

Who has the rearrangement?

Egg provider Sperm provider

How was it discovered?

Infertility Oligozoospermia Low AMH Recurrent miscarriage Routine investigation

📊 PGT-A

Thank you — PGT-A (aneuploidy screening) is used to assess embryos for chromosome number abnormalities which become more common with age. We'll review your full history and discuss suitability during your consultation.

Section D — Previous Investigations

Investigation Results

Please indicate which investigations you've had and provide results where available.

📋 Blood Tests & Screening

🔬 Imaging & Procedures

Review

Questionnaire Complete

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