Tubal Reversal Pregnancy Form

* First Name

* Last Name (at the time of surgery)

  Current Last Name (if changed)

  City

  State

  Country

  Doctor who performed your surgery Dr. Berger
Dr. Monteith

  Date of your tubal reversal

  Date of last menstrual period

  Date of positive pregnancy test

  Due Date

  Number of pregnancies since TR

  Outcome of previous pregnancies

  Ligation method Tubal clips (clamps)
Tubal rings (bands)
Resection (tied or cut)
Coagulation (burned)
Fimbriectomy
Essure
Other/unknown

  Did you use an ovulation predictor kit with this conception Yes
No

  Did you use any fertility medications with this conception Yes
No

  If so, what medications

* Email

  Work phone

  Home phone

  Cell phone

* Permission to Publish. Yes
No