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Note: For women going through IVF only
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1
. How old are you?
How old are you?
Under 30
31-35
36-40
Over 40
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2
. Are you married or in a serious relationship?
Are you married or in a serious relationship?
Yes, I'm married
Yes, I'm in a serious relationship
No
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3
. Do you have children?
Do you have children?
Yes
No
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4
. Have you gone through infertility treatment with a previous pregnancy?
Have you gone through infertility treatment with a previous pregnancy?
Yes
No
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5
. Has anyone else in your family experienced infertility?
Has anyone else in your family experienced infertility?
Yes
No
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6
. How old were you when you started infertility treatment?
How old were you when you started infertility treatment?
Under 30
31-35
36-40
Over 40
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7
. If you waited until over 35 to try to get pregnant, why?
If you waited until over 35 to try to get pregnant, why?
I wasn't married yet
I was busy with my career
Partner wasn't ready
I didn't wait
Other (please specify)
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8
. What options have you already tried to combat infertility? Select all that apply.
What options have you already tried to combat infertility? Select all that apply.
Fertility drugs
Surgery
Intrauterine insemination (IUI)
Alternative approaches such as acupuncture or Chinese herbs
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9
. How much time a month are you spending on IVF (research, doctor's visits, travel to and from doctor, shots, etc.)?
How much time a month are you spending on IVF (research, doctor's visits, travel to and from doctor, shots, etc.)?
Under 15 hours
Between 15 and 25 hours
Over 25 hours
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10
. How much money would you be willing to spend on infertility treatments in order to get pregnant?
How much money would you be willing to spend on infertility treatments in order to get pregnant?
Less than $30,000
$30,000 to $50,000
$50,000 to $100,000
More than $100,000
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11
. Does your health insurance cover infertility treatments?
Does your health insurance cover infertility treatments?
No
Yes, some of it
Yes, all of it
I don't have insurance
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12
. How has IVF affected your sex life?
How has IVF affected your sex life?
It's better
It's worse
It hasn't affected it
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13
. How stressed do you feel about going through IVF?
How stressed do you feel about going through IVF?
Extremely
Somewhat
Not at all
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14
. Which side effects have you experienced from the hormones you take for IVF? Choose all that apply.
Which side effects have you experienced from the hormones you take for IVF? Choose all that apply.
Bloating
Acne
Mood swings
Sore or tender breasts
Cramps
Nausea or vomiting
Fatigue
I haven't experienced any side effects
Other (please specify)
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15
. How many times a day do you typically think about getting pregnant?
How many times a day do you typically think about getting pregnant?
Fewer than 5
5-20
More than 20
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16
. How has the IVF process affected your relationships with friends and family?
How has the IVF process affected your relationships with friends and family?
It's strengthened them
It's strained them
It hasn't affected them
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17
. Who do you turn to for help dealing with infertility? Choose all that apply.
Who do you turn to for help dealing with infertility? Choose all that apply.
Friends
Family
Partner
Online forums
Real-life support group
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18
. How has infertility affected your relationship with your partner?
How has infertility affected your relationship with your partner?
It's strengthened it
It's weakened it
It hasn't affected it
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19
. Would you be willing to risk your relationship with your partner to get pregnant?
Would you be willing to risk your relationship with your partner to get pregnant?
Yes
No
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20
. How do you feel around women who are pregnant?
How do you feel around women who are pregnant?
Happy for them
Jealous and/or depressed
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21
. At what point did you decide to do IVF after trying to get pregnant on your own?
At what point did you decide to do IVF after trying to get pregnant on your own?
Less than 6 months
Between 6 and 12 months
Between 12 and 18 months
More than 18 months
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22
. How far do you travel for IVF treatment?
How far do you travel for IVF treatment?
Less than a half-hour
Between a half-hour and an hour
Between an hour and two hours
More than two hours
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23
. Are you hoping for twins as a result of IVF treatment?
Are you hoping for twins as a result of IVF treatment?
Yes
No
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24
. Are you concerned about the possibility of high-order multiple pregnancy (triplets or more) as a result of IVF treatment?
Are you concerned about the possibility of high-order multiple pregnancy (triplets or more) as a result of IVF treatment?
Yes
No
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25
. If you get pregnant with high-order multiples (triplets or more), would you consider selective reduction (terminating one or more fetuses)?
If you get pregnant with high-order multiples (triplets or more), would you consider selective reduction (terminating one or more fetuses)?
Yes
No
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26
. How many times would you consider doing IVF to help you conceive?
How many times would you consider doing IVF to help you conceive?
1-2
3-4
5-6
7-8
More than 8
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27
. At what age you would no longer be willing to pursue IVF (whether with your own or donor eggs)?
At what age you would no longer be willing to pursue IVF (whether with your own or donor eggs)?
Under 35
35-40
41-45
Over 45
Age would not be a factor for me
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28
. If IVF does not work for you, would you consider adoption?
If IVF does not work for you, would you consider adoption?
Yes
No
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29
. What alternative approaches, if any, have you tried to help you conceive? Choose all that apply.
What alternative approaches, if any, have you tried to help you conceive? Choose all that apply.
Acupuncture
Chinese herbs
Meditation
Group therapy/stress reduction
I have not tried any alternative approaches
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