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510.841.1858
Making the dream of family a reality since 1982
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Pregnancy Report
Phone:
510.841.1858
Fax:
510.841.0332
Email:
click here
Privacy Policy
1
Recipient's name (person who conceived)
*
Your e-mail address
*
Partner's name (if applicable)
Is your partner a registered TSBC recipient? (if applicable)
Yes
No
If Yes - has she ever conceived with TSBC sperm?
Yes
No
Have you moved?
New address
New address - City, State, Zip
New home phone number
New cell phone number
2
Recipient's age at time of insemination
*
Donor #
*
Due Date:
3
Please give us the details for this conception cycle.
What cycle number is this?
*
- Select -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Other
A "cycle" is each time you ovulate. How many cycles total (including this one) have you inseminated using TSBC vials?
Total # of vials used this cycle?
*
- Select -
1
2
3
4
5
Include information from this cycle only. Do not include details from previous attempts that did not result in pregnancy.
Total # of Inseminations this cycle?
*
- Select -
1
2
3
4
5
Total # of vials "not" used this cycle? (i.e. still at doctor's office)
*
- Select -
0
1
2
3
4
5
Other
How were the vials transported?
Shipped
Picked-up
If you picked up, did you use:
Liquid Nitrogen Tank
Dry Ice
4
Please give us the details of your insemination process for THIS cycle only- Do not include previous attempts that did not result in pregnancy.
Date of 1st Insemination
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2010
2011
2012
2013
2014
An "insemination" is an attempt made at pregnancy during your fertile "cycle"
# of vials used for 1st insemination
*
- Select -
1
2
3
4
Method of Insemination:
*
Vaginal Pool (includes intra-cervical, ICI)
Intra-uterine (IUI)
IVF
ICSI
Insemination Setting
*
Home
Clinic/MD office
Other
If other, please specify
Date of 2nd Insemination
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2010
2011
2012
2013
2014
# of vials used for 2nd insemination
- None -
1
2
3
4
Method of Insemination:
Vaginal Pool (includes intra-cervical, ICI)
Intra-uterine (IUI)
IVF
ICSI
Insemination Setting
Home
Clinic/MD office
Other
If other, please specify
Date of 3rd Insemination
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2010
2011
2012
2013
2014
# of vials used for 3rd insemination
- None -
1
2
3
4
Method of Insemination:
Vaginal Pool (includes intra-cervical, ICI)
Intra-uterine (IUI)
IVF
ICSI
Insemination Setting
Home
Clinic/MD office
Other
If other, please specify
5
If your method was IVF, are the insemination date(s) above for:
Retrieval
Transfer
Did you use a surrogate?
Yes
No
Did you use egg donation?
Yes
No
If yes, did you use:
Partner's eggs
Donor eggs
Surrogate's eggs
6
Means to determine ovulation: (check all that apply)
Ovulation predictor kit
Ultrasound
Cervical exam
Fertility monitor
Blood test/s
Basal body temp
Mucus
Controlled cycle (i.e. IVF)
Mittelschmerz pain
HCG trigger shot
Other
If other, please specify
Did you use fertility drugs for this conception?
None used
Clomid
HCG
Repronex
GonalF
Menopur
Other
If other, please specify
7
How many pregnancies have you had with TSBC? (including this one)
- None -
1
2
3
4
5
6
7
8
9
10
Do you have other TSBC children?
Yes
No
If yes, how many?
- None -
1
2
3
4
5
6
7
8
9
10
What is your parenting arrangement?
Single
Couple
Other
If "couple" what is the gender of your partner?
Female
Male
Transgender
If other, please specify
8
How do you identify?
*
LBQ
Heterosexual
Other
Decline to state
If other, please specify
If LBQ, do you identify as:
Lesbian
Bisexual
Queer
Other
If other, please specify
9
Are you interested in purchasing sibling inventory?
Yes
No
Maybe
This question helps us determine how many vials of a particular donor to save. The only way to guarantee availability however is to purchase vials that you plan to use in the future.
Additional Questions/Comments:
