Reproductive Endocrinologist (Infertility and Fertility Preservation)
Chief Complaint:
Sarah is a 32 y.o. interested in fertility preservation.
Desired Number of Children:
2
Occupation:
Marketing Manager at GlobalTech Solutions
Gynecologic History
* Menarche: 13 years old
* Menstrual cycle frequency: 28-32 days
* Duration of menses each month: 5 days
* Irregularity of menstrual cycles or excessive bleeding: Occasional mild spotting mid-cycle, otherwise regular. No excessive bleeding.
* Date of last known menstrual period: 28 October 2024
* History of abnormal Pap smears: None reported
* Gynecologic surgery including laparoscopy and hysteroscopy: None
Obstetric History
Total number of pregnancies and outcomes: 0 pregnancies.
Previous Infertility Testing
None.
Previous Fertility Preservation Treatment
None.
Past Medical and Surgical History, Allergies and FHx
* Chronic medical conditions: Mild hypothyroidism, well-controlled with medication.
* Past surgical procedures: Appendectomy at age 10.
* Current medications: Levothyroxine 50 mcg daily, Multivitamin daily.
* Allergies: Penicillin (hives).
* Family history: Mother with early menopause (age 45), father with hypertension.
1. Fertility Preservation Counseling
- Current issues, reasons for visit, history of presenting complaints relevant to issue 1: Sarah, a 32-year-old female, presents to discuss her options for fertility preservation. She states, "I'm focused on my career right now and don't see myself having children for at least another 5-7 years, but I'm worried about my fertility declining." She expresses concern due to her mother experiencing early menopause. She is healthy with no known fertility issues at present but wants to be proactive.
- Past medical history, previous surgeries, medications relevant to issue 1: As above, mild hypothyroidism and appendectomy. No medications impacting fertility. No previous reproductive surgeries.
- Objective findings, vitals, physical or mental state examination findings relevant to issue 1: General physical examination within normal limits. Vitals: BP 120/78, HR 72, Temp 36.8°C. Appears well and articulate.
- Likely diagnosis for issue 1: Elective fertility preservation.
- Differential diagnosis for issue 1: Age-related fertility decline, familial early menopause.
- Investigations planned for issue 1:
* Anti-Müllerian Hormone (AMH) test
* Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH) on cycle day 3
* Estradiol on cycle day 3
* Transvaginal ultrasound for antral follicle count (AFC)
- Counseling:
* Description of the condition: We discussed the natural age-related decline in ovarian reserve and egg quality, which typically accelerates after the mid-30s. We reviewed how egg freezing (oocyte cryopreservation) offers a way to preserve fertility for future use.
* Natural history: Explained that without intervention, her ovarian reserve and egg quality will naturally decrease over time, potentially making conception more challenging in her late 30s and 40s.
* Risks/benefits: Benefits include preserving reproductive options, reducing age-related risks to future pregnancies, and peace of mind. Risks include those associated with ovarian stimulation (e.g., OHSS, discomfort) and egg retrieval (e.g., bleeding, infection, damage to adjacent organs), as well as the emotional and financial investment. Patient was informed that freezing eggs does not guarantee a future live birth.
* Alternatives: Alternatives discussed include attempting natural conception sooner or pursuing adoption/donor gametes in the future. Sarah confirmed her desire to preserve her own genetic material.
* Key counseling comments: "I understand that this isn't a guarantee, but I feel like it's the best option for me to control my future." Counseling included a detailed explanation of the process, success rates based on age at freezing, and the importance of timely action.
- Plan: Proceed with baseline fertility workup (AMH, FSH, LH, E2, AFC). Schedule a follow-up appointment to review results and discuss stimulation protocol options for egg retrieval.
Target Consideration
“Based on current age of 32, and using available online egg freezing counseling tools, we discussed that having 10 mature oocytes would yield an approximately 70% chance to achieve one live birth.”
Action Plan
* Baseline fertility blood tests (AMH, FSH, LH, E2) ordered for cycle day 3.
* Transvaginal ultrasound for Antral Follicle Count scheduled for 1 November 2024.
* Follow-up consultation scheduled in 2 weeks to review results and plan ovarian stimulation.
* Financial clearance initiated for egg freezing cycle.
(Write this as a reproductive endocrinologist specializing in infertility and fertility preservation, using a moderate amount of details and inserting quotes from the patient where appropriate, and including counseling comments)
Chief Complaint:
[patient first name] is a [patient age in years] y.o. interested in fertility preservation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (If the patient has cancer, add: due to [type of cancer] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.))
Desired Number of Children:
[desired number of children] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Occupation:
[occupation and employer]
Gynecologic History
[Using bullet points: age at first menses (menarche); menstrual cycle frequency (range of days); duration of menses each month; any irregularity of menstrual cycles or excessive bleeding; date of last known menstrual period (include only if mentioned; otherwise omit) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.); history of abnormal Pap smears; gynecologic surgery including laparoscopy and hysteroscopy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Obstetric History
[Total number of pregnancies and outcomes: total number of miscarriages, abortions, biochemical pregnancies, ectopic pregnancies, and live births (entire section can be omitted if patient has never been pregnant) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous Infertility Testing
[Using bullet points: summarize previous infertility investigations (organized by: lab results; uterine imaging studies including hysterosalpingogram; saline infusion sonogram; hysteroscopy results; and partner semen analysis results). If it is explicitly stated there was no prior testing, report “none”.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Previous Fertility Preservation Treatment
[Summarize previous fertility preservation treatment, including any details reported by the patient such as medications used, number of oocytes collected, number of mature MII oocytes frozen; if embryo preservation, include number of embryos frozen and how many embryos were chromosomally normal (euploid). If it is explicitly stated there was no prior treatment, report “none”.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical and Surgical History, Allergies and FHx
[Using bullet points: chronic medical conditions; past surgical procedures; current medications (including vitamins and supplements); allergies (including medications, environmental, and dietary restrictions); and family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
1. [Medical issue, problem or request 1 (condition/request name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current issues, reasons for visit, history of presenting complaints relevant to issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Past medical history, previous surgeries, medications relevant to issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Objective findings, vitals, physical or mental state examination findings relevant to issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Likely diagnosis for issue 1 (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis for issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations planned for issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Counseling: using bullet points, include description of the condition, natural history, risks/benefits, alternatives, and key counseling comments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Plan: proposed plan for management or follow-up for issue 1] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [Medical issue, problem or request 2, 3, 4, etc. (condition/request name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current issues, reasons for visit, history of presenting complaints relevant to issue 2, 3, 4, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Past medical history, previous surgeries, medications relevant to issue 2, 3, 4, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Objective findings, vitals, physical or mental state examination findings relevant to issue 2, 3, 4, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Likely diagnosis for issue 2, 3, 4, etc. (condition name only)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Differential diagnosis for issue 2, 3, 4, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Investigations planned for issue 2, 3, 4, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Counseling: using bullet points, include description of the condition, natural history, risks/benefits, alternatives, and key counseling comments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Plan: proposed plan for management or follow-up for issue 2, 3, 4, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Target Consideration
[“Based on current age of” [patient current age] “, and using available online egg freezing counseling tools, we discussed that having 10 mature oocytes would yield an approximately ” [estimated chance of a singleton live birth] “ chance to achieve one live birth.”] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Action Plan
[Using bullet points: proposed plan for management or follow-up, including any administrative actions needed (e.g., financial clearance) and timeframe for next follow-up appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Keep in mind that the transcript may be about a variety of topics, from medical conditions, to mental health and social concerns, to dietary and exercise discussions and you must always attempt to use the transcript to create an list of topics discussed using the template above. Use as many bullet points as necessary to ensure clinical information is adequately spaced for easy reading comprehension.)