Thank you for your interest in our study named, Vascular Health After In Vitro Fertilization or HEART-IVF. Women eligible for this study will be invited to the University of Anschutz Medical Campus to undergo testing. Study procedures include intravenous (IV) catheter placement, blood draws, surveys and measures of blood pressure and vascular function. We have attached a copy of the full informed consent document if you wish to review this study in greater detail. However, you do not need to sign the document now. We will do this together, if we believe you may be eligible for this study. To see if you qualify for the study, we ask that you fill out some questions, which will include questions about your menopausal and health history. It should take about 10 minutes to go through these questions. Some of the questions may make you uncomfortable; you do not have to answer any question that you would not like to answer, but without answers to these questions, you will not be eligible to participate in the study. Your information will be kept secure. After reading the above text, would you like to be screened for eligibility for the HEART-IVF Study?
Yes No
Thank you for your interest in our study. You have answered you do not wish to complete this screening survey. You may exit out of this window, if you wish to not complete this survey or express interest in this study. If this answer is in error, you may change your response to complete the survey. Are you between the ages of 18-45 years?
Yes
No
What is your current age?
Do you have a regular (every 24-31 days) period?
Yes
No
Are you premenopausal? Yes
No
Are you on birth control?
Yes
No
Are you currently using hormone replacement therapy (HT)?
Yes No
Are you currently pregnant, breastfeeding or wishing to become pregnant in the next 3 months?
Yes No
Intention to become pregnant includes initiation of IVF treatment.
If yes, which:
Pregnant
Breastfeeding
Wishing to become pregnant in the next 3 months
How many children have you given birth to?
Did you have a pregnancy that resulted in a live birth within the past 1 to 5 years?
Yes No
Was this pregnancy conceived through Assisted Reproductive Technology (ART)?
Yes No
If yes, was this pregnancy conceived via in vitro fertilization (IVF)?
Yes No
If yes, what was the reason for IVF?
Male infertility or no male-partner
Female infertility
Unexplained or idiopathic infertility
Mixed-factor infertility or some combination of the above
Other
If yes, was the reason for IVF due to male-factor infertility or the lack of a male partner? Male-factor infertility is defined as semen abnormalities that result in the inability to conceive even though the female is fertile.
Yes No
Have you ever been diagnosed with polycystic ovary syndrome (PCOS) or diminished ovarian reserve (DOR)?
Yes
No
During your pregnancy or pregnancies, did you develop any complications such as gestational hypertension, preeclampsia, eclampsia, HELLP syndrome, gestational diabetes, preterm birth, small for gestational age, etc?
Yes
No
Other
If other, please describe.
What is your approximate weight? lbs
Height: Feet
Height: Inches
Calculated height View equation
BMI View equation
Do you currently smoke or have you lived with a smoker in the past 12 months?
Yes No
Do you regularly exercise? Yes
No
Please describe types of exercise, frequency and duration
Are you currently taking any prescription medications, vitamins, or anti-inflammatory medications (e.g. aspirin, ibuprofen)?
Yes No
Medication or Vitamin Name #1
Medication or Vitamin #1 Frequency
Medication or Vitamin #1 Reason
Medication or Vitamin #2 Name
Medication or Vitamin #2 Frequency
Medication or Vitamin #2 Reason
Medication or Vitamin #3 Name
Medication or Vitamin #3 Frequency
Medication or Vitamin #3 Reason
Do you take any additional medications or vitamins? Yes
No
If yes, please list the name, frequency and reason below.
Diabetes or high blood sugar
Yes No
Cancer
Yes No
Heart disease
Yes No
High blood pressure or hypertension
Yes No
Stroke
Yes No
Liver disease
Yes No
Gallbladder Disease
Yes No
Kidney disease
Yes No
Have you experienced a serious illness within the last 6 months?
Yes No
Have you had a confirmed positive COVID test and hospitalized?
Yes No
Have you had a confirmed positive COVID test within the last 6 months?
Yes No
Race American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or other Pacific Islander
More than one race
Undeclared/unknown
Refused to answer
Missing
Ethnicity Non-Hispanic
Hispanic
Undeclared/unknown
Refused to answer
Missing
Do you have morning availability during the week to come into the University of Colorado Anschutz Medical Campus to complete study procedures?
Yes No
Are you willing to have your blood drawn through an intravenous (IV) catheter?
Yes No
Are you willing to fast overnight for 12-hours? Yes
No
Are you willing to wear a sleep or blood pressure monitor overnight while you sleep?
Yes No
Are you willing to washout of over-the-counter vitamins, supplements and minerals for the duration of the study?
Yes No
May we contact you via phone or email to tell you more about the study?
Yes No
First and Last Name
Email
Phone Number Best phone number to reach you during work hours
Date of Birth Today M-D-Y
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