Azoospermia Form

Consultation Form

  • Please answer the following questions about your case.
  • Once you complete this form, we will contact you by email if this treatment is right for you or not.
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Do you have Non-Obstructive Azoospermia or Obstructive Azoospermia?
Can you write your FSH level?Please write the units
What is your LH levels?Please write the units
What is your Testosterone levels?Please write the units
Do you know what type of Azoospermia you have?
Did your DNA test indicate any microdeletion in Y chromosome?You can use Prolistem treatment even you have microdeletion in chromosome Y, but in this case you need to consider testicular sperm extraction after the treatment. Microdeletion in chromosome Y lower the chances to find sperm in the semen.
Do you know the reason for your Azoospermia?(Azoospermia could be for many reasons that we know and most of them we don't know)
Have you had testicular sperm extraction (TESE) for IVF done before?(if yes can you give more details)
What is your sperm count analysis results (recently)?pick one!
What kind of treatments you tried in the past?
Do you have any heart disease, high blood pressure or diabetes?People with the following conditions should not take Prolistem® Stage I and Stage II treatments: heart failure, heart disease, fluid retention, high blood pressure (hypertension), diabetes, kidney disease and liver disease.
Do you have any additional information that we should know?
How did you find us?
What is your age?
What country do you live in?Prolistem can be ship worldwide
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