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    3 views1 page

    IVF2

    Uploaded by

    baselbibo

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Fertility Center

    File No.
    Intracytoplasma Sperm Injection
    And in Vitro Fertilization
    Wife’s Name: Wife’s age:
    Husband Name: Husband age:
    Address Tel. No.: Infertility (1° or 2°):
    Physcian Name: Dr. Infertility Period:

    Semen Source: Ejaculated: FNA: Biopsy


    Before Wash After Wash
    Count (x10⁶ ImL) Motilty(%) Count (x10⁶ ImL) Motilty(%)

    Notes: Type Media Used:

    FNA:Phylician Dr. : Signature


    Notes:
    Testicalar Biopsy : Phylician Name Dr.: Signature
    Notes:
    Lab Director (Phycian Name) Signature
    Notes:

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