Clinical module
The patient file, from first contact to diagnosis
FertiliCore gives each patient a single IVF file carrying demographics, referral pathway and infertility duration, then builds the work-up on top of it. The Infertility File workspace holds anamnesis, examinations, gynaecological findings, coded diagnoses and OHSS surveillance in one place.
- One file per patient, female and male linked as a couple
- Seeded female and male infertility diagnosis vocabularies
- Twelve-criterion OHSS grading scale shipped pre-loaded
- Consanguinity recorded as an explicit genetic-risk flag
One dossier per patient, one link per couple
Infertility is treated as a couple but recorded as two people. FertiliCore therefore opens a separate patient file for the female and the male partner, each with its own file number, demographics, blood group, occupation, referral pathway, presenting complaint and duration of infertility in months. The couple record then joins the two files, and it is that couple link the treatment cycle attaches to. The registration screen merges the identity fields and the clinical front sheet into one form, so the registrar never sees the underlying split between the person record and the clinical file.
- Patients list, create form and detail drawer are built screens
- Detail drawer carries General Info, change History and Files tabs
- Files are deactivated and restored rather than destroyed
- Legacy file numbers and external hospital references are retained for traceability
Partnership history, including consanguinity
The couple record models more than a pointer between two files. It captures the marriage date and duration, the number of prior marriages on each side, and whether the partners are blood relatives together with the degree of relatedness. Consanguinity is a genetic-risk flag, not a demographic curiosity: it changes the counselling conversation and the threshold for carrier screening, so it belongs in structured data where a report can find it. The couple link is currently maintained through the API rather than a dedicated registration page.
The Infertility File workspace
Once a patient is registered, the longitudinal work-up is recorded in the Infertility File workspace. It is gender-aware, so each panel presents the fields relevant to that partner, and it is organised as five tabs: Anamnesis, Examinations, Diagnoses, Gynaecological Exam and OHSS Tracking. The intention is that a clinician can complete a first work-up without leaving the workspace, and that a later reader can reconstruct the reasoning behind the treatment plan.
- Anamnesis: file history, itemised medical and surgical history, review of systems
- Examinations: HSG, hysteroscopy, laparoscopy and laparotomy records
- Diagnoses: coded female-factor and male-factor lists with ICD code and primary flag
- Gynaecological Exam: cervix, uterus and bilateral adnexal findings
- OHSS Tracking: cycle-linked risk assessments
History that is countable, not narrative
Obstetric and menstrual history drives prognosis, so it is entered as discrete fields rather than a paragraph. Gravidity, parity, abortions, ectopics and living children are separate counts. Menarche age is constrained to 6-25 years and BMI to 10-80, which stops transcription slips from silently entering the record. Menstrual regularity, infertility type and working aetiology are chosen from fixed lists. Past illnesses and operations are logged one row each, with year and hospital, so a prior myomectomy or ovarian cystectomy is visible at a glance rather than buried in free text.
The operative and imaging record set
Tubal and uterine assessment is recorded procedure by procedure. The HSG record holds right and left tube status, uterine cavity appearance and a reference to the stored image. The hysteroscopy record covers procedure type, anaesthesia, findings, intervention and complications. Laparoscopy is the richest of the set: bilateral tubal patency at surgery, endometriosis stage constrained to 1-4 on the standard minimal-to-severe staging, and explicit flags for fibroids and adhesions, alongside findings and intervention. Laparotomy is recorded where a case was managed open, with the indication stated.
OHSS surveillance and the laboratory work-up
Ovarian hyperstimulation syndrome is the principal safety risk of stimulation, so each assessment is tied to a named treatment cycle and records the parameters that grade it: serum oestradiol, follicle count, weight, abdominal circumference, urine output, haematocrit, and whether the patient was admitted. A twelve-row criteria table spanning mild to critical ships pre-loaded to back that grading. Laboratory results are entered against a shared test catalogue, so selecting an assay fills in the name and unit and the result carries a normal or abnormal flag against a reference range. The record also models lot-level traceability of laboratory consumables back to a patient, cycle and procedure date.
Field level
What the record actually holds.
Structured fields, not a free-text note — which is what makes the reporting and the registry returns downstream possible.
Identity and demographics
- File number, assigned or generated
- Gender, date of birth and place of birth
- National identity number
- ABO and Rh blood group
- Address, city and country of residence
- Occupation and education level
- Emergency contact name and telephone
Referral and presentation
- Coded referral channel from a seeded list
- Free-text referral source and referring doctor
- Initial presenting complaint
- Duration of infertility in months
Couple and partnership
- Female and male partner file links
- Marriage date and duration in years
- Prior marriage counts for each partner
- Consanguinity flag and degree of relatedness
Reproductive and medical anamnesis
- Gravidity, parity, abortions and ectopic pregnancies
- Number of living children
- Menarche age and menstrual cycle length
- Menstrual regularity and dysmenorrhoea
- Contraception history
- Chronic disease, current medication and allergies
- Smoking status with pack-years, alcohol use
- Body mass index
- Primary or secondary infertility, working aetiology
- Past illnesses and operations with year and hospital
- Review of systems across ten body systems
Examination and operative findings
- External genitalia, vaginal and cervical findings
- Cervical smear taken or not
- Uterine size, position, mobility and tenderness
- Right and left adnexal findings
- HSG tubal status and uterine cavity appearance
- Hysteroscopy findings, intervention and complications
- Laparoscopic tubal patency, both sides
- Endometriosis stage 1 to 4
- Fibroids and pelvic adhesions present or absent
- Laparotomy indication, findings and intervention
Diagnosis, safety and laboratory
- Coded female-factor or male-factor diagnosis
- ICD code and primary-diagnosis flag
- OHSS risk grade with oestradiol and follicle count
- Weight, abdominal circumference, urine output, haematocrit
- Hospital admission for OHSS, yes or no
- Catalogued lab result with unit and reference range
- Normal or abnormal interpretation flag
- Performing laboratory, in-house or external
Common questions
Does each partner get a separate record, or one shared couple record?
Each partner has their own patient file, with its own file number, demographics and clinical history. A separate couple record links the female and male files and carries the partnership detail, including consanguinity. Treatment cycles attach to that couple link, so the male work-up and the female work-up stay joined without being merged into one document.
Are the infertility diagnosis lists fixed, or can we use our own terminology?
The system ships with seeded female-factor and male-factor vocabularies covering the standard categories, and the correct list is loaded automatically from the patient's recorded gender. Both lists remain administrator-editable, so a centre can extend or rename entries to match its own reporting conventions. Each diagnosis can also carry an ICD code and free-text elaboration.
How is OHSS risk tracked?
Every OHSS assessment is tied to a specific treatment cycle and records the grading parameters alongside the overall risk level: oestradiol, follicle count, weight, abdominal circumference, urine output and haematocrit, plus symptoms, management plan and whether the patient was admitted. A twelve-criterion reference table covering mild through critical is pre-loaded to support consistent grading between clinicians.
Can a record be corrected after it has been signed off?
Clinical records carry a lock flag that freezes an entry once it is finalised, and several record types use it, including the file history, the gynaecological examination and the discharge note. Nothing is physically erased: records move between active, inactive and deleted states and can be restored. Every record also carries who entered it and when, with a field-level change history visible on the patient detail drawer.
What happens to laboratory results for assays that are not in the catalogue?
The catalogue standardises code, name, unit and reference range for the seeded endocrine assays, and selecting an entry auto-fills name and unit on the result form. It is deliberately small and intended to be grown by the clinic. Results for assays not yet catalogued are not blocked: the result form accepts a free-text test name alongside the value, unit and reference range.
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