Egg Donor Profiles

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EDC0180617

Profile

GENERAL DETAILS

  1. Age:     26                                                        Year of Birth: 1991
  2. Husband’s Age: 31
  3. Native: Avanashi
  4. Height: 156 cm
  5. Weight: 40 kg
  6. Education: Middle school                               From   Year2001 to    2002Year
  7. Religion: Hindu
  8. Veg/Non-Veg: Both
  9. Nationality: Indian

10.    Identity Proof: Voter ID & Aadhar card

11.    Blood Group: A1 Positive

12.    Languages known: Tamil, Malayalam

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Physical Appearance

  1. Physical Build             Medium

 

           

  1. Skin Complexion                     dark

 

  1. Eye Color:                               Black
  2. Hair Color:                               Black
  3. Natural Texture of Hair:                      Thin                       

Marital Status

Married                   

 

 

  1. Date of Marriage:        23.02.2012
  2. Has your husband accompanied you for the interview? Yes        

If not, reason for the same:

  1. Have you been married more than once?      No
  2. Does your husband agree?                            Yes
  3. Do you have a marriage certificate or any proof of marriage?

Yes            

If yes, Proof Type  marriage invitation                                    ID Number

 

PERSONAL CHARACTER

  1. Please describe your personality and character?

calm type

  1. What do you like most about yourself?

Soft nature

  1. What are your hobbies and interest?

Watching tv and caring my child

  1. What is the work that you would love to do most?

House work

  1. How do you emotionally feel about being an egg donor?

Feel happy

  1. What was your most interesting subject in your education?

Tamil

  1. How attached are your towards your family?

Very close

 

HABITS

  1. Do you use tobacco or do you smoke?                      No
  2. Do you consume alcohol?                                          No
  3. Does your husband use tobacco?                 No
  4. Does your husband consume alcohol?                      Yes (Weekly once)

PREGNANCIES

  1. Have you ever had a fertility problem?                       No
  2. If YES, please give details
  3. Have you had a multiple birth?                                   No
  4. How many children do you have?

Male

 

Female

2

           

  1. Have you ever suffered a miscarriage?                     No
  2. Have you undergone MTP?                           No
  3. Have you ever any ectopic pregnancies?      No
  4. Have you suffered a stillbirth?                                    No
  5. Have you suffered from Post-natal Depression? No

If yes, please provide details of the same.

 

  1. Have you undergone surrogacy earlier?                    No
  2. Have you taken up egg donation earlier?      No

If yes, please provide details of the same.

 

 

 

  1. Please give details of deliveries:

 

1

2

3

4

Normal/

C-Section

C- Section

C- Section

 

 

Dates of Birth

24.01.2013

24.12.2014

 

 

Weight

3.500

3.000

 

 

Was pregnancies full term?

10 months

10 months

 

 

Did any of your children have a medical problem at birth

No

No

 

 

Do any of your children have health problems? (Physical or Psychological)

No

No

 

 

 

FAMILY PLANNING

  1. Have you done family planning?                                No  
  2. Present contraception method?                                 Yes            
  3. Has your husband done family planning?      No
  4. If answer to the above two questions is No, do you understand the importance of abstaining from Intercourse at the time of ovulation?

Yes

  1. Have you completed your family?                              Yes            

 

MEDICAL

  1. Have you gained or lost over 10 kilos in the past six months?

No

If yes, please give details

  1. Have you been immunized?                           Yes
  2. Have you ever had any psychiatric problems?          No
  3. Are you presently taking any medication?     No
  4. Do you have any diseases, such as, diabetes/epilepsy, etc.

No

6.     Are you known allergic to any particular drug or substance/food?

No                .

7.     How long is an average monthly cycle for you?                      28        days

8.     How long do your periods last?                                               5          Days

9.     LMP: 10.06.2016

10.  Do you wear glasses?                         No

If yes, what is the type and power?

 

FAMILY MEDICAL HISTORY:

  1. Does anyone in your family have any genetic diseases, such as, diabetes, epilepsy or any heart problem?          No
  2. Does anyone in your family have twin children?        No
  3. Is there some medical condition in your family that you might consider would pass on genetically?                                                No

 

MEDICAL (PARTNER):

1.     Is your husband suffering from disease that is transmittable orally, such as, TB, etc.                                                                    No

2.     Is your husband suffering from any Sexually Transmittable Disease?

No

3.     Is your husband suffering from any psychiatric problem or any mental issue?                                                                     No

 

SUPPORT

  1. Do you have someone to offer practical and emotional support?

Yes

Name and relation: Somu (Husband)

  1. Is your family aware of your intention to become a surrogate mother/egg donor?

Yes            

 

Convenience

  1. If chosen, how far are you prepared to travel to a clinic?                  Within Coimbatore    
  2. Are you willing to travel to any other city other than your present residence?                                                        Yes             2 hours travel

 

EMPLOYMENT:

  1. Are you currently employed?                          No  
  2. Occupation/Nature of work:               
  3. Previous occupation:  gold covering manufacture
  4. If YES, how many hours a day/week?           8 hours                                   
  5. Would your employer allow you time off to attend hospital/clinic appointments for treatment etc.?                                    Not applicable
  6. If you are employed or have been employed, what is the pay that you had been receiving? Nil
  7. Is your spouse currently employed?               Yes            
  8. Nature of work/occupation of your spouse: Tailor.

 

 

 

Family details

Please write a short statement about you, your family, and most importantly your reasons for wanting to be a surrogate mother/egg-donor. Please also mention other information you wish to communicate to the intended parents.

Nuclear family

LEGAL COUNSELLING

Are you being forced into taking up the egg donation/surrogacy arrangement by anyone? Yes

Are you willing to be a surrogate mother/egg donor only out of your Free Will?

Yes            

Do you or your spouse have any criminal convictions, or criminal proceedings pending?                                                No

EGG DONOR

1.               Do you know that you have to complete your family before you can get enrolled with Gift lifes Egg Donor Program?

Yes            

2.               Do you know that you have a risk of becoming infertile, if selected?

Yes            

3.               Are you informed of the following:

(a)             The basic process of Egg Donation   Yes            

(b)              The gametes (eggs) that would be retrieved from you by ART by stimulation with hormonal drugs would be the sole property of the childless couple.                                                             Yes            

(c)             You would have no control over the gametes that have been retrieved from you or the child that may be created/born out of such gametes?

Yes            

(d)             You still remain an anonymous Egg Donor, shall have no knowledge of who would be using your gametes?                      Yes            

(e)             You would not be making any attempt to identify the childless couple whom you are helping.                                         Yes            

4.               Do you have any doubts/queries?

 

 

COMPENSATION:

  1. What is your monthly income? Nil
  2. What is the monthly income of your family? Rs.8,000/-
  3. Do you or anyone in your family own any movable or immovable assets? No
  4. If you were selected, how much compensation according to you would be appropriate for your services?

Rs.40,000/- to Rs.45,000/-

  1. What would you do with the compensation that would get out of this effort?

To settle debts

  1. Something that you would like to communicate to childless couple that you would help in the process?

We wish them to have child and for their future life.

 

 

 

Comments by interviewer