Fertility Assessment

Fertility Assessment Patient Information: Sarah Jones, 32, Teacher, and her partner, David Jones, 35, Architect. Reason for Visit: Patient presents with a one-year history of trying to conceive without success. She reports regular menstrual cycles but is concerned about her age and potential fertility issues. She is seeking advice and assessment. Obstetric History: No previous pregnancies. Menstrual History: Regular cycles, 28 days with 5 days of bleeding, no significant associated symptoms. Sexual History: Patient reports sexual intercourse 2-3 times per week. No contraception is currently being used. No history of sexually transmitted diseases. Medical History: No significant past medical history. No previous surgeries. Medications: None. Allergies: No known allergies. Social History: Non-smoker, drinks alcohol occasionally (1-2 units per week). Lives with her partner. Family History: No family history of infertility or relevant medical conditions. Lifestyle Factors: Patient maintains a healthy diet and exercises regularly. Reports moderate stress levels related to work. Physical Examination: BMI: 24. Physical examination unremarkable. Partner History: David Jones has no known fertility issues. He is in good health and takes no medications. No relevant family history. Assessment: Primary infertility. Further investigations are required to determine the cause. Investigations: Ordered: Day 3 FSH, LH, oestradiol, and AMH blood tests. Referral for semen analysis for partner. Plan: Discussed the results of the blood tests and semen analysis with the patient. Advised on lifestyle modifications, including stress reduction techniques. Referred to a fertility specialist for further evaluation and management. Follow-up appointment in 4 weeks to review results and discuss next steps. Advised to take folic acid supplement.