Male Fertility Questionnaire

Part one · Everyone

Your details, and anything affecting anaesthesia.

Short, and the same on every form. The blood-thinner question matters most: several of the procedures I perform can be done without stopping them, but only if that is planned in advance.

Full name

Date of birth

Best contact number

GP practice

Are you taking any blood-thinning medication?

Warfarin, apixaban, rivaroxaban, edoxaban, dabigatran, clopidogrel, ticagrelor, aspirin.

Yes No

Have you been diagnosed with diabetes?

Yes No

Have you had previous urological surgery or pelvic radiotherapy?

Yes No

All other regular medications

Allergies

Part two · History

How long, and what has already been looked at.

Sperm production runs on a cycle of about 74 days, so much of what matters happened months ago. Both partners' histories shape the plan, which is why some of these questions are about your partner.

Have you ever fathered a pregnancy, with any partner?

Regardless of the outcome. It separates primary from secondary infertility, which point at different causes.

Yes No

How many months have you been trying to conceive?

Your partner's age

Has your partner been investigated, and what was found?

Any previous IVF or ICSI cycles — how many, and what happened?

Have you had a semen analysis?

Yes No Not sure

Part three · Anatomy and exposures

The things that are correctable.

Most of what can be treated surgically or reversed by changing something shows up in these questions rather than on a semen analysis.

Do you get a dull ache or a feeling of heaviness in the testicles, particularly after standing a long time?

Yes No

Has anyone told you that you have a varicocele?

Yes No Not sure

Any of these in your history?

An undescended testicle as a child Groin or hernia surgery Injury or torsion of a testicle Mumps after puberty Chemotherapy or radiotherapy A vasectomy Recurrent urinary or genital infection None of these

Have you ever taken testosterone, or anabolic steroids?

Including gels, injections, pellets, or anything from a gym or an online source. This is the most important question on this form and there is no judgement attached to the answer — testosterone shuts sperm production down, it is usually reversible, but only if we know about it.

Yes, currently Yes, in the past No

Which of these apply to you?

You smoke or vape Regular saunas, hot tubs, or a hot working environment Long hours sitting or driving A laptop on your lap regularly You take fertility supplements or antioxidants Heavy endurance training More than 14 units of alcohol a week Recreational drug use, including cannabis None of these

How often do you ejaculate, on average?

Long gaps do not improve the sample — sperm stored for more than a few days accumulate DNA damage.

Every 1–3 days About weekly Less often

Any difficulty with erections or with ejaculating?

Yes No

Anything else you would like me to know?

Half the answer is usually male. Let's look properly.

Your details, and anything affecting anaesthesia.

How long, and what has already been looked at.

The things that are correctable.

Your summary