Embryo Donation Program in Arizona

I/we consent to receive donor embryos from Arizona Center for Fertility Studies to be used for uterine transfer. I/we have had the screening tests for receiving donor embryos as set by the American Society of Reproductive Medicine and the FDA. I/we are aware the embryo donors have been screened also, according to ASRM and the FDA. All reasonable measures have been taken to ensure that the donor remain anonymous. It is understood that Arizona Center for Fertility Studies cannot be responsible for the physical or mental characteristics of any child or children produced. Any child born of this procedure will be regarded as my/our natural child in all respects including the laws of descent and distribution of property. I/we waive all rights to challenge the legitimacy of any child/children born from this procedure, and to provide all reasonable support to said child/children. All records and agreements remain confidential, and cannot be released without my/our permission.

I/we consent to the following general steps involved in uterine embryo transfer.

1. Administration of hormone injections to time the thaw and prepare the uterine lining.
2. Monitoring of the uterine lining with vaginal ultrasound.
3. A pre-determined number of embryos will be thawed in the laboratory under microscopic examination to assess viability based on ASRM guidelines.
4. Once viability is confirmed, a pre-determined number of embryos will be transferred into the uterus by a small catheter inserted through the cervix.

I/we have been informed of the following procedures, risks and limitations and have had the opportunity to discuss these with my physician.

1. Transferring the embryos into the uterus may cause slight discomfort, cramping, spotting, or infection, although these side-effects are quite uncommon.
2. There is a possibility of ectopic pregnancy with any attempt at pregnancy. This would require treatment by MTX (methotrexate) or surgery to remove the ectopic pregnancy.
3. The transfer of multiple embryos may result in multiple gestation. The risks of prematurity and other complications have been explained.
4. It is possible, although extremely unlikely, that infection could be introduced into the patient by this procedure.

I/we understand that any of the following may occur to prevent pregnancy.

1. Medical emergencies may make the transfer unavailable.
2. The embryo(s) may not survive the thaw process.
3. The embryo(s) may not develop normally and therefore would not be transferred.
4. Implantation may not occur.
5. A laboratory accident may result in loss or damage to the embryo(s), although this has never happened at Arizona Center for Fertility Studies.

The goal of this procedure is to achieve a normal pregnancy. Once a pregnancy is established, miscarriage, ectopic pregnancy, stillbirth and/or congenital abnormalities may occur. There is no evidence to date that the occurrence of these is increased or decreased by this procedure. I/we understand that several attempt may be necessary to achieve a pregnancy.

I/we understand that if I or any of my off spring should require medical treatment as a result of physical injury arising from participation in this process, the financial responsibility will be mine. I/we understand the financial responsibility associated with this procedure.

Data from this procedure will be provided to the Centers for Disease Control and Prevention(CDC). The 1992 Fertility Clinic Success Rate and Certification Act requires the CDC to collect data on all assisted reproductive technology cycles in the US. SART (Society for Reproductive Technologies) uses this information to confirm and report success rates. Because this is sensitive information, the CDC and SART applied for and received an "assurance of confidentiality" for this project under the provisions of the Public Health Service Act, Section 308D. This means that any information that CDC has that identifies you cannot be disclosed to anyone without your consent.