Consultation en ligne

Online Consultation, Form for free Gynecological, Infertility consultation

Dr Najeeb Layyous IVF Center in Jordan would be happy to provide a free online consultation to your problem. He will do his best to answer all queries. Please refer to Frequently Asked Questions before submitting your query.

Free Consultation In Facebook Page

IN CASE YOU HAVE PRIVATE PROBLEMS Please email your details in the following format, so that he can guide you more effectively. The better the question you ask, the better his answer will be !

Copy and paste the form, fill in the details, and them email it to


Name _____________________________________Occupation____________

Partner Name_______________________________

Home Phone ____________________ Business phone ________________Fax No____________

Address ________________________________________________________

E-Mail _____________________________________________

City _______________________ State _________________ Postal Code _________________


How long have you been married?_____________

How long have you been trying to get pregnant? ________________

How long have you been trying to get pregnant with a doctor's help?___________

Was it a General Gynecologist or a Reproductive Endocrinology and Infertility Specialist? _________

About how many times a month do you have intercourse? _____

Does either partner smoke? _____________ How much? ___________

Does either partner use recreational drugs? ________ Which ones? _____________________


Age_____ Birth date ________ Height_________ Weight_________

Blood group ______________________Allergies to medicines _________

Menstrual periods occur every ________ days. Are they regular? __________Amount of bleeding ____

For how many days do you bleed? _________ Do you have endometriosis? ______

Do you have any medical problems? ______ If yes, please give details, including any medications _______________________________________________________________



Have you ever had pelvic inflammatory disease (PID)? ______________________

What pelvic surgeries have you had? ____________________________________

What were the findings? _____________________________________________ ________________________________________________________________

Number of pregnancies with this partner _______

Number of pregnancies with a previous partner _______

Number of miscarriages _______

Number of abortions __________

Number of tubal pregnancies ________

Number of live births _________


Have you had:

















How many

Any success?

Clomiphene stimulation with intercourse




Clomiphene stimulation with insemination




Injectable FSH stimulation

(Metrodin, Humegon, etc.) with intercourse




Injectable FSH stimulation with insemination




Inseminations without any stimulation




In vitro fertilization




In vitro fertilization with ICSI







What else should we know about your case?

Are there other pertinent test results, procedures or problems that have been identified?

Give details of IVF results, if applicable:

-Stimulation Protocol _______________________________________

-No. of follicles ___________________________________________

-No. of eggs _____________________________________________

-No. of embryos transferred _________________________________

-No. of frozen embryos ____________________________________

-Out come ______________________________________________


Age______________ Birth date ________________ Height ____________ Weight ________

Occupation ___________________ Allergies to medicines ______________ Blood group___

- Prior marriage __________________________________________________

- Number of pregnancies with a previous partner _________________________

- Do you have problems with evection or ejaculation ?_____________________


- Male medical problem ___________________________________________

- Current medications _____________________________________________

- Hormonal blood test _____________________________________________

- Previous surgeries _______________________________________________

- Family history of infertility _________________________________________

- Previous treatment for infertility _____________________________________

- Semen analysis :

Volume ________________ PH _______________Date of test_____________

Liquefaction ________________

Count _____________________

Motility ________________ Type 1 ____________ Type 2 ___________

Type 3 ___________ Type 4 ___________

Normal forms __________________

WBCs _________________________ RBCs _________________________

If you had Azoospermia :

Have you ever had testicular biopsy ? _________________________________

Date __________________________

Result ________________________________________________________


Ask specific questions that you would like addressed.



E- mail or Fax us this form along with copies of your relevant medical records

Dr. Layyous will then review the material and make a written report (including recommendations). Alternatively, he will speak with you on the phone regarding your case - if you prefer.

Last Update: 2011-09-01