DHEA Infertility Trial Screening Form

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DHEA Study —

Letrozole Study —

"Safety of fertility preservation by ovarian stimulation with letrozole and gonadotropins in patients with breast cancer."
"Letrozole reduces estrogen and gonadotropin exposure in women with breast cancer undergoing ovarian stimulation before chemotherapy."

We are asking you to fill out this form because you have expressed an interest in participating in a clinical trial. Women who consent to participate in this trial will be randomly assigned to take either DHEA (a weak hormone) or a placebo. Neither you nor your treating physician will know what treatment you are using until the end of the study. Women participating in this study will not receive any other treatment than the study medications. We have preliminary evidence that suggests that women with open tubes who have a partner with normal sperm count may improve their chance of pregnancy by using DHEA. This study is designed to test whether this observation is a true effect of treatment, or just a coincidence.

* Answer required

Are you interested in participating in this study? *
(If you answer "No," you are finished with this form.
Yes
No, I do not want to participate.

Do you understand that participants will receive either DHEA or a Placebo (sugar pill)? *
Yes
No

Please enter your first name: *

Please enter your last name: *

Please enter your Email address: *

What is your phone number?

What is your cell phone or work number? *

What is your zip code?

What is your birthdate? (mm/dd/yy)*

How old are you today?

Have you been living in this area at least 18 months?
Yes
No

Are you presently enrolled in any other research study? *
Yes
No

How would you identify your racial group? *
( If you are of mixed background, which do you do identify with the most?)
White (Caucasion
African
Asian or Pacific Islander
Middle Eastern
Native American
Other

Do you consider yourself to be Hispanic? *
(Ethnic Hispanic individuals include many different racial backgrounds.)
Yes
No

How old were you when you had your first period? *

Are your cycles shorter than 24 days? *
Yes
No

Are your cycles longer than 34 days? *
Yes
No

How many times have you been pregnant? *

Any miscarriages? *
None
1 to 2
3 or more

How do you know your fallopian tube(s) are open? *
I had a laparoscopy
I had an HSG (x-ray study) to see if my tubes are open.
Don't know

Other:

Ever had a pregnancy terminated? *
Never
Once or twice
Three or more

Have you ever had a tubal pregnancy? *

Yes
No
Don't know

Have you ever had surgery on your uterus or fallopian tubes?

Yes
No
Don't know

Are you married or with a partner? *

Yes
No

How long have you been trying to become pregnant? *

Do you have at least one open fallopian tube?

Yes
No
Don't know

When was the test of your tubes performed?

Within 2 years
More than 2 years
No test performed

If you were tested, what kind of test was performed?

Does your husband/partner have a normal semen
analysis? *

Yes
No
Don't know

How much do you weigh (in pounds)? *

How tall are you in inches? *
(5" equals 60-inches; 5' 2" equals 62, etc.)

By placing your initals in the space below you agree to allow us to contact you further about this study.

Thank you for filling out this form. If you have had a test of your tubes and your husband has had a normal semen analysis, please have your doctor fax your reports to 312.876.1804, c/o DHEA Inferility Trial; or email the documents as attachments to mdixon@infertilitytrials.com; After we have reviewed your answers to these questions and have received copies of your previous testing, we will call you to come to our office in Manhattan to begin the study.