Please complete the brief application below to see if you qualify!

Last Name *

First Name *

Email *

Phone *

I Consent to Receive SMS Notifications from The IVF Center. Message frequency varies. Message & data rates may apply.

1. Have you been diagnosed with PCOS (Polycystic Ovary Syndrome)?*

2. Are You Seeking Immediate Fertility? *

3. Are You Between the Ages of 18-40? *

4. Do you have a BMI of less than or equal to 40? *

5. Have you taken ovulation induction medications such as letrozole or clomiphene citrate without subsequent ovulation, or are you contraindicated for or declined such treatment?

6. How did you hear about the REBALANCE Study? *

7. Have you ever had surgery on one or both ovaries or fallopian tubes? *

8. Have you ever been treated with injectable gonadotropins (injectable FSH or HMG like Follistim, Memopur, Gonal-F) for infertility?

How many cycles have you completed?

9.This clinical research study involves invasive imaging and procedures such as a transvaginal ultrasound to determine eligibility. Are these tests and procedures something you would be willing to complete? *

10. The study procedure involves transvaginal (via the vagina) ultrasound guidance to visualize the ovary. Once the ovary is visualized, a thin needle is inserted through the vaginal wall and into the ovary, similar to the technique routinely used for egg retrieval for IVF. Radiofrequency energy is then delivered to gently heat the surrounding ovarian tissue. Is this investigational procedure something you would be willing to complete? *

11. This clinical research study requires weekly blood tests (for up to six months) and follow up phone calls and clinic visits over a 36-month (3 year) period. Are these follow up requirements something you would be willing to complete?

You are a potential candidate for the REBALANCE Study

Do you grant May Health or its affiliates permission to refer you to a study site in your area?

Yes

In which city and state do you currently reside?

You are not a candidate for the REBALANCE Study. Thank you for your time!