FertiQol Page

Instructions

For each question, kindly select the option for the response that most closely reflects how you think and feel.

Relate your answers to your current thoughts and feelings. Some questions may relate to your private life, but they are necessary to adequately measure all aspects of your life.

Please complete the items marked with an asterisk (*) only if you have a partner.

FertiQoL International

Fertility Quality of Life Questionnaire (2008)

Patient name

Your Email

Date

For each question, check the response that is closest to your current thoughts and feelings

A. How would you rate your health?

For each question, check the response that is closest to your current thoughts and feelings

B. Are you satisfied with your quality of life?

For each question, check the response that is closest to your current thoughts and feelings

Q1. Are your attention and concentration impaired by thoughts of infertility?

Q2. Do you think you cannot move ahead with other life goals and plans because of fertility problems?

Q3. Do you feel drained or worn out because of fertility problems?

Q4. Do you feel able to cope with your fertility problems?

For each question, check the response that is closest to your current thoughts and feelings

Q5. Are you satisfied with the support you receive from friends with regard to your fertility problems?

Q6*. Are you satisfied with your sexual relationship even though you have fertility problems?

For each question, check the response that is closest to your current thoughts and feelings

Q7. Do your fertility problems cause feelings of jealousy and resentment?

Q8. Do you experience grief and/or feelings of loss about not being able to have a child (or more children)?

Q9. Do you fluctuate between hope and despair because of fertility problems?

Q10. Are you socially isolated because of fertility problems?

Q11*. Are you and your partner affectionate with each other even though you have fertility problems?

Q12. Do your fertility problems interfere with your day-to-day work or obligations?

Q13. Do you feel uncomfortable attending social situations like holidays and celebrations because of your fertility problems?

Q14. Do you feel your family can understand what you are going through?

For each question, check the response that is closest to your current thoughts and feelings

Q15*. Have fertility problems strengthened your commitment to your partner?

Q16. Do you feel sad and depressed about your fertility problems?

Q17. Do your fertility problems make you inferior to people with children?

Q18. Are you bothered by fatigue because of fertility problems?

Q19*. Have fertility problems had a negative impact on your relationship with your partner?

Q20*. Do you find it difficult to talk to your partner about your feelings related to infertility?

Q21*. Are you content with your relationship even though you have fertility problems?

Q22. Do you feel social pressure on you to have (or have more) children?

Q23. Do your fertility problems make you angry?

Q24. Do you feel pain and physical discomfort because of your fertility problems?

FertiQoL International Optional Treatment Module

Have you started fertility treatment (this includes any medical consultation or intervention)? If Yes, then please respond to the following questions. For each question, kindly select the response that most closely reflects how you think and feel. Relate your answers to your currentthoughts and feelings. Some questions may relate to your private life, but they are necessary to adequately measure all aspects of your life.

For each question, check the response that is closest to your current thoughts and feelings

T1. Does infertility treatment negatively affect your mood?

T2. Are the fertility medical services you would like available to you?

For each question, check the response that is closest to your current thoughts and feelings

T3. How complicated is dealing with the procedure and/ or administration of medication for your infertility treatment(s)?

T4. Are you bothered by the effect of treatment on your daily or work-related activities?

T5. Do you feel the fertility staff understand what you are going through?

T6. Are you bothered by the physical side effects of fertility medications and treatment?

For each question, check the response that is closest to your current thoughts and feelings

T7. Are you satisfied with the quality of services available to you to address your emotional needs?

T8. How would you rate the surgery and/or medical treatment(s) you have received?

T9. How would you rate the quality of information you received about medication, surgery and/or medical treatment?

T10. Are you satisfied with your interactions with fertility medical staff?

I hereby certify that, to the best of my knowledge, the information provided is true and accurate to support my fertility journey with Fertile Ground’s roadmap.

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