[Patient name] Sarah Jones, 32, Teacher, works in a primary school. Followed by [Partner name] David Smith, 35, Architect, works for a large firm.
**AMH levels** 1.2 ng/mL
[Reason for patient visit, e.g., primary infertility/secondary infertility] Primary infertility
[Previous fertility treatment details, location, and doctor] None
[General medical diagnosis relevant to infertility or obstetrics] None
Past Medical History: Nil significant
Past Surgical History: Appendectomy at age 10
Mental Health History: No history of mental health issues
Family History: Mother with early menopause
Medications: Folic acid 400mcg daily
Past Obstetric and Gynaecology History:
G: 0
P: 0
[Pregnancy outcomes and complications] N/A
Menstrual Cycles: Regular, 28-day cycle, 5 days of bleeding
HMB: No
Dysmenorrhoea/Dyspareunia/Dyschezia: Mild dysmenorrhoea
PID/STI: No history
CST: 2022, normal
Contraception: Previously used combined oral contraceptive pill, stopped 6 months ago
Pelvic Ultrasound: Normal uterus and ovaries, AFC 10
Social History:
Home with [Who patient lives with] Partner
Work: Teacher
Smoking: Non-smoker
ETOH: Occasional social drinking
Weight: 65 kg
Height: 165 cm
BMI: 23.9
Ix: Female screening bloods, pelvic US completed.
Partner:
Partner: David Smith, 35, present
Healthy: No known medical conditions
Past Medical History: Nil significant
Past Surgical History: Nil significant
Mental Health History: No history of mental health issues
Family History: Nil significant
Medications: Nil
Previous Pregnancies: None
Non-smoker
ETOH: Occasional social drinking
No sexual dysfunction
No mumps/trauma to testes
MSB: Normal
SA: Normal
Karyotype: Not discussed
Expanded GCS: Not discussed
[Partner investigations discussed] Semen analysis discussed and planned.
Discussion:
Discussed the results of the initial investigations. Explained the implications of the AMH level and the importance of further investigations, including a semen analysis for the partner. Discussed lifestyle factors and the importance of a healthy weight and diet. Discussed the possibility of ovulation induction and IUI.
[#] Genetic carrier screening and costing discussed
[#] Options discussed: Ovulation induction, IUI, IVF. Benefits, risks, and success rates of each discussed.
Plan:
Arrange semen analysis for partner. Review results in 2 weeks. Discuss further treatment options based on results. Follow-up appointment scheduled for 15 November 2024.
