(Anonymous Donor)
Donor’s Name
Donor’s Husband (if applicable)
Date of Birth
Purpose of Procedure: The purpose of this procedure is to utilize a technique which will stimulate the oocyte (egg) donor to produce more than one egg, which, when fertilized, can then be transferred to an infertile woman in order to enable her to chance to become pregnant. A child conceived of this method will carry the donor’s genetic material rather than that of the woman who bears the child.
The technique requires the use of drugs to stimulate the growth and development of the ovaries’ eggs. Fertility drugs may be administered orally (clomiphene citrate), subcutaneously (leuprolide acetate, Follistim, Gonal-F, Ovidrel), intramuscularly (Follistim, Gonal-F, hCG) and/or nasal spray
(nafarelin). These drugs enjoy a widespread clinical use for the production of multiple eggs in women.
Independent Contractor: I understand that I am acting as an independent contractor in donating my eggs and that I am not an employee of Bellingham IVF & Infertility Care.
Anonymity: Unless I expressly authorize, in writing, to the disclosure of my identity to the infertile couple who will receive my eggs, my name and any facts that would lead to my identity will not be disclosed to them. I specifically instruct Bellingham IVF & Infertility Care to keep my identity confidential. If Bellingham IVF & Infertility Care feels it is medically necessary, it may reveal nonidentifying information about me to the infertile couple, and I authorize it to do so.
I understand that I will undergo the following:
1.
OVARIAN STIMULATION: To start the stimulation I will need to inject subcutaneously
Lupron (leuprolide acetate) or use a nasal spray Synarel (nafarelin) and then add injections of
Follistim/Gonal-F and/or Repronex daily. This medicine regularly produces multiple eggs per cycle instead of the usual one egg per cycle.
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2.
MONITORING: To monitor the response to the medicine, blood will be drawn daily or every other day to measure hormones (estradiol levels) which reflects the maturity of the eggs. This will begin just prior to the initiation of the cycle and daily throughout the stimulation part of the cycle. Pelvic ultrasound exams will also be performed using a vaginal probe throughout the cycle of stimulation to better assess the number and maturity of the ripening eggs.
Pelvic Ultrasound Examinations: The growth of the ovarian follicles will be monitored by transvaginal ultrasound. Ultrasound is a diagnostic procedure using high frequency sound waves that provide a picture of the ovaries and growing follicles
Withdrawal of Blood: To monitor the development of the eggs(s), two (2) teaspoons of blood will be drawn daily or every other day to measure hormones (estradiol levels) which reflect the maturity of the eggs. This monitoring will begin just prior to the initiation of the study and daily throughout that part of the cycle in which the egg(s) are developing.
3.
OVULATION TRIGGERING: To complete the final maturation of multiple eggs being recruited by the stimulation medication, a hormone called human chorionic gonadotropin (hCG) is injected intramuscularly or subcutaneous one time. This is followed by aspiration of the oocytes (egg(s)) approximately 34 hours later. Ultrasound guided needle aspiration will be performed at that time under intravenous sedation.
4.
ULTRASOUND GUIDED EGG RETRIEVAL: After I receive medicine to sedate and relax me, each egg will be removed (aspirated) using a needle that is introduced through the back wall of the vagina directly into the ovary and into the ovarian follicle. This may cause some minor discomfort and localized bleeding. The procedure is performed under direct vision using ultrasound. Usually it takes about 40 minutes or less time to accomplish. I will be monitored for approximately 30-60 minutes by a nurse prior to discharge. This procedure is relatively painless, and I should be able to resume normal activity the next day.
THE FOLLOWING ARE SOME OF THE RISKS AND DISCOMFORTS WHICH I MAY
EXPERIENCE FROM THE OVARIAN STIMULATION AND EGG RETRIEVAL
PROCEDURE.
1.
OVULATION INDUCTION: Occasional hot flashes and temporary visual changes (blurring and accommodation changes). Ovarian cyst formation that may cause pain in the lower abdomen. Rarely, hyperstimulation (OHSS) may occur. This condition may require a hospital stay resulting from a large number of ovarian follicles with ovarian enlargement and producing an accumulation of fluid in my abdomen/pelvis, with resultant electrolyte imbalance, discomfort and distention. Chance of a severe hyperstimulation requiring a hospital stay is 1-2:100. The risks of these complications are low.
2.
ULTRASOUND EXAMINATION: Women undergoing transvaginal ultrasound may feel mild discomfort from the passage of the probe into the vagina.
3.
BLOOD DRAWING: This may produce discomfort at the site of the needle insertion as well as localized swelling and skin discoloration (bruising).
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4.
INTRA-ABDOMINAL AND PELVIC BLEEDING AND SCARRING: Although highly unlikely, as a result of the egg retrieval significant bleeding, or infection or both may occur in the pelvis. The needle used to aspirate the follicular fluid may injure the bowel, bladder, blood vessels, ovaries, uterus or tubes. If severe, this could require hospitalization, and emergency surgery. Although considered extremely unlikely, a small possibility exists that as a result of an infection from this procedure, I subsequently may have scarring in my pelvis, which may render me infertile.
5.
EMOTIONAL DISTRESS: There may be psychological anguish or distress associated with the performance of this procedure.
6.
GONADOTROPIN THERAPY: I willingly and freely consent to the administration of
Follistim, Gonal-F, hCG, Lupron and/or Synarel.
WAVERS: The woman receiving my egg(s) and her husband/partner will be the parents of any child born as a result of the use of these donated egg(s). As a result of my donation of these egg(s), they (recipient and husband/partner) will assume all parental, custodial, inheritance and testamentary rights to any offspring that might result from the transfer of resulting embryos to the uterus of the recipient. I understand and expressly agree that the recipient and her husband/partner shall be conclusively presumed to be the legal parents of any child(ren) conceived pursuant to this IVF/ET
(In Vitro Fertilization/Embryo Transfer) procedure. I have been informed that the couple receiving eggs(s) from me as a result of this procedure has acknowledged, in writing, that they will accept all rights and duties of parenthood of any child conceived as a result of this procedure.
Furthermore, I waive any right to make legal claims against the recipient couple, doctors involved in this procedure and Bellingham IVF & Infertility Care with regard to parental rights including issues of disclosure of information, visiting rights, shared custody, inheritance and maternity.
I understand that the undersigned physician(s) and their associates, unless compelled by law, will make all reasonable efforts to keep information obtained about me during the course of medical management, confidential. I agree that specific medical details may be revealed in professional publications, as long as my identity will not be revealed to the media or to any other person without my prior authorization.
I acknowledge that I have adequate understanding of the In Vitro Fertilization and Embryo Transfer process as described in this document and by the physician(s) at Bellingham IVF & Infertility Care, and I have been provided with all information I have requested. I have been made aware of the usual and most frequent risks and hazards inherent in the procedures described. I understand that there may be some risks that are not known at this time. I have had the opportunity to ask all pertinent questions and these have been answered to my satisfaction. I expressly understand and accept that this procedure, and the treatment associated with it, will be performed by the undersigned physician(s) and their associates in full accordance with the customary standard of medical care.
I understand and agree that responsibility for all the medical expenses arising out of the egg retrieval shall be paid by the recipients and that they have agreed, in writing, to pay for any post surgical complications not covered by medical insurance. I understand that their financial obligations to me are limited to any medical problem related to this procedure that might result in the three (3) month
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period after the egg retrieval. I understand they are not responsible for any psychological damage that I may suffer as a result of my egg donation. In the event I do not have health insurance, such insurance shall be provided to my by the recipients prior to instigation of the egg retrieval, to cover any unforeseen medical complications arising out of the said retrieval.
In the event of a medical emergency arising out of this procedure, emergency medical care is available, but will not be free of charge.
I accept $ (US Dollars) as reasonable monetary compensation for my participation in this IVF/ET procedure. I consent, and have been informed that the infertile couple has likewise agreed to the placement of all known and estimated expenses and payment involving this procedure into a trust account for my benefit.
I expressly agree that the infertile couple shall not be liable for wages, childcare, transportation, or any other expenses incurred by me as a result of my donation to them, unless expressly provided herewith.
I have read and full understand this consent from and sign it freely and voluntarily and in the knowledge that a copy shall be given to me upon execution.
I acknowledge and understand that there are legal questions raised by the issues involved in this agreement which have not been settled by statute or prior court decisions. Notwithstanding the knowledge that certain clauses stated herein may not be enforced in a court of law, I choose to enter into this agreement and clarify my intent to proceed with the donor oocyte (egg) donation involving hormone therapy.
I have been advised by Bellingham IVF & Infertility Care to seek the advice of an attorney prior to signing this agreement, so that I may be full advised of my rights, potential risks, and responsibilities under this agreement. I have elected to proceed with the oocyte (egg) donation procedure with/without seeking the advice of independent counsel. I understand the terms of this contract and the medical risks involved in the procedure, and I sign this consent freely and voluntarily.
I expressly acknowledge that this agreement is executed under the penalty of perjury.
Donor Signature
Donor’s Husband/Partner (if applicable)
Witness Signature
Date
Date
Date
I have consulted with and explained the contents of this agreement to the above named donor and
Husband/Partner (if applicable).
Emmett F. Branigan, M.D. Date
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