Letter to referring doctor

Dr. Eleanor Vance 123 Fertility Clinic Lane London, UK Date: 1 November 2024 Dear Dr. Vance, Re: Emily Carter, DOB: 12/03/1988 Thank you for referring Emily Carter to my care for investigation of primary infertility. Clinical Summary: Emily, a 36-year-old female, presents with a 2-year history of trying to conceive without success. She has regular menstrual cycles. Her partner, John, has had a semen analysis which was normal. Current Presentation: Emily reports no significant symptoms. She is concerned about her age and the time it is taking to conceive. Her functional status is good; she is working full-time and maintaining an active social life. Past Medical History: - No significant past medical history. - Family history of early menopause in her mother. Medications: - Folic acid 400mcg daily. - No known drug allergies. Examination Findings: Physical examination was unremarkable. BMI 24. Pelvic exam normal. Investigations: - Day 3 FSH: 8.2 IU/L - AMH: 1.8 ng/mL - Pelvic ultrasound: Normal uterus and ovaries. No evidence of fibroids or cysts. Antral follicle count: 8. Impression/Diagnosis: Primary infertility, likely related to diminished ovarian reserve. Management Plan: - Discussed options for fertility treatment, including ovulation induction with timed intercourse, intrauterine insemination (IUI), and in vitro fertilisation (IVF). - Recommended further investigations, including a hysteroscopy to assess the uterine cavity. - Offered counselling regarding the emotional aspects of infertility. - Scheduled follow-up appointment in 4 weeks to review hysteroscopy results and discuss treatment options in more detail. Thank you again for your referral. I will keep you updated on Emily Carter's progress. Yours sincerely, Dr. Thomas Kelly Consultant Reproductive Endocrinologist The Fertility Clinic 020 7123 4567