Download 01 - Egg Donor Invitation Letter - Atlanta Center for Reproductive

Lisa A. Hasty, MD, FACOG
André L. Denis, MD, MPH FACOG
Jim Toner, MD, PhD, FACOG
Sue Ellen Carpenter, MD, FACOG
Robin Fogle, MD, FACOG
David L. Keenan, MD, FACOG
Reproductive Endocrinology and Infertility
(770) 928-2276
email: [email protected]
fax (770) 592-2092
www.atlantainfertility.com
Chad A. Johnson, PhD, HCLD
Reproductive Studies Laboratory Director
Steven A. Voelkel, PhD, HCLD
Director of Research
Steven C. Gerson, CPA, MPAcc
Chief Financial Officer
Dear prospective egg donor:
We are excited about your interest in donating eggs to infertile couples who desperately need
them! Know that these couples will be forever grateful to you for this gift of life! It is only
by gifts such as yours that many couples can achieve their dream of having children, and we
are sincerely appreciative.
In order for you to donate eggs, we need to be sure that you meet the strict criteria to be an
egg donor. Some women are not accepted as egg donor candidates because of their age or
their family history.
Please look over the pages attached. The first one gives an overview of what is involved in
becoming an egg donor. If this process is something you still feel interested in, we invite you
to proceed. Complete the questionnaire included in this packet, and with 3 pictures of
yourself (including one when you were a child), please mail them back to us in the enclosed
envelope. All questions on the questionnaire must be completed – incomplete applications
will automatically be declined. After we look over your answers to the questionnaire, you
will be notified if you qualify as a potential egg donor.
We hope you will be able to participate in our egg donor program. You could make a couple
very happy through the donation of your time. We pledge our best efforts to be as
accommodating to your schedule as possible.
Sincerely,
Bernadette Wooten, RNC
Third Party Coordinator
Jim Toner MD, PhD
5909 Peachtree Dunwoody Road, Suite720, Atlanta, GA 30328
35 Collier Road, Suite M-125, Atlanta, GA 30309
6470 East Johns Crossing, Duluth, GA 30097
100 Stone Forest Drive, Suite 300, Woodstock, GA 30189
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THE EGG DONATION PROCESS
Part One: Becoming a Donor
Step 1. Screening for medical and genetic problems
•
•
Send us your pictures and the completed questionnaire in the envelope provided.
We’ll call you back within one week to let you know the results of the questionnaire review. If
things look good, we’ll invite you to proceed to Step 2.
Step 2. Donor Orientation meeting
During this one-hour long meeting, we will review the donor egg process with you in detail. The
final steps of screening will then be arranged if you remain interested.
Step 3. Final screening
Meetings with a counselor, physician, and nursing staff will then be scheduled, and a few
laboratory tests will be performed. If everything is normal, you will enter our donor pool.
Step Two: Egg Donation
Our goal is to safely retrieve multiple eggs from your ovaries with the least possible disruption to your
schedule. Inevitably, however, there will be some degree of inconvenience, and for this reason you will
be reimbursed financially (see below) and we hope, psychologically.
You will be given medications over a period of 8—12 days to stimulate multiple eggs to grow. Because
every woman is different, we will need to monitor your particular response by periodic hormone checks
and ultrasound examinations of your ovaries during this period of time. We will need you to be available
during the early mornings (before 9:30 a.m.) to monitor your response. Though you won’t need to come
every day, we won’t know ahead of time which days you’ll have to come and which you won’t, so your
schedule must be flexible. We’ll be able to provide any letters to your employer that you need to get this
time off.
After the eggs have been appropriately stimulated, we will remove them from your ovaries in a brief
procedure using ultrasound as a guide while you are completely anesthetized. You’ll go home about an
hour after we’re done. [Later that day your eggs will be inseminated for the benefit of the couple(s)
receiving them.]
When your next period comes, we’d like you to come by the office one last time for an ultrasound to
make sure everything’s returned to normal.
Remember that we’ll explain all these steps in greater detail at your orientation appointment, and are
happy to answer any questions you have.
Other Issues:
•
Reimbursement:
$6000 per cycle
•
Limit:
5 cycles
•
Anonymity:
strictly enforced
•
Complications: possible; will be reviewed in detail at your consultation visit.
Egg Donor Application
Date:
_____________________
Name: _______________________________
Birthdate: ________________________
Address: ______________________________
SS # ______________________________
______________________________
Height: ________
Telephone numbers where you may be reached:
Weight: ________
OK to leave voice mail?
_____
Home
(_____) ___________________________
Yes / No
_____
Work
(_____) ___________________________
Yes / No
_____
Cell
(_____) ___________________________
Yes / No
Occupation: _________________________________
Employer: _________________________
How did you find out about the Egg Donor program?
q Advertisement in: ________________________
q Other: __________________________________
q Friend
q Doctor
How many pregnancies have you had? __________
How many children: _____
Do you have a recipient already? ________________
Her relationship to you: _____________
Your husband / partner: _______________________
His occupation: ____________________
Emergency Contact: name: ____________________
Phone: ___________________________
Remember to include in the return envelope:
•
3 photographs of yourself (2 recent, 1 as child)
•
the completed questionnaire
•
your prior medical records
______ I have enclosed the photographs, questionnaire, and medical records
My medical records have been requested from the following doctor:
______________________________________
______________________________________
______________________________________
Egg Donation Information
What is an egg donor program?
Egg donation is a process by which eggs (oocytes) are provided by one woman and given to
another woman. The egg donor can be a friend, family member, or an anonymous donor. The
process of retrieving eggs from a woman requires In Vitro Fertilization (IVF) and the technique
of egg donation is an extension of the IVF Program. Before understanding how the use of
donor eggs is incorporated in a couples' treatment cycle and what you would have to undergo
in order to donate your eggs, it is important for you to understand the definition of IVF and
the various stages of the process.
Definition of In Vitro Fertilization
IVF describes fertilization of an egg by sperm outside the body. The egg, once fertilized, is
termed the embryo. Once fertilization and early development has occurred, the embryo
(which has divided into multiple cells) is replaced into the uterus. Therefore, apart from the
initial fertilization procedure that normally occurs in the mother's fallopian tube, the
remaining development of the embryo occurs naturally within the woman's body. IVF was
originally devised as a way of allowing women who had blocked, absent or non-functioning
fallopian tubes to establish a pregnancy. Subsequently, the reasons to carry out IVF have
increased dramatically, and today it is one of the most successful methods available to allow
an infertile couple to establish a pregnancy.
Many IVF clinics exist worldwide, and success is steadily increasing in these centers as
techniques for ovulation induction, egg recovery, laboratory procedures, and embryo
replacement are being refined. Over 50,000 babies have been born worldwide as a result of
IVF.
PHASES OF THE IVF PROCESS:
The phases of an IVF treatment cycle can be divided into four basic phases:
1.
2.
3.
4.
Ovulation Induction
Egg Retrieval
Laboratory Preparation of Eggs and Sperm
Embryo Replacement
As an egg donor in our IVF program, you would participate in the first two phases of ovulation
induction and egg retrieval. The third and fourth phases refer to the recipient couple.
Ovulation Induction for the Egg Donor
Success with the IVF procedure is increased if more than one embryo is replaced in the
uterus. Ideally, we like to replace two or three embryos in a treatment cycle, as this will
provide the best chances for the recipient to get pregnant with one baby.
Since we ideally will have more than one embryo available for replacement, we need to have
more than one egg available for fertilization. The number of eggs we get from the woman
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donating eggs will influence the likelihood of establishing pregnancy for the recipient couple.
Furthermore, if we are able to retrieve more eggs than are needed for that treatment cycle,
the excess embryos that result from the donation can be cryopreserved (frozen) for later use.
In order for us to achieve the goal of obtaining more than one egg from the donor and to
accurately control the time of ovulation, it is necessary to use medications to stimulate the
ovaries to produce more than one egg.
The medications we typically use for this purpose are:
Lupron
Bravelle
Follistim
Menopur
hCG
Lupron is the first drug you may take and is begun about 7 days before the donor begins her
period in the cycle in which egg donation takes place. It is an injection given just underneath
the surface of the skin (a “subcutaneous” injection like insulin used daily by diabetics). This is
used so that the pituitary gland does not release the necessary hormones to stimulate the
production and growth of the egg in your natural cycle. Therefore, your own cycle is "turned
off" (much like when birth control pills are taken). This medication (Lupron) will be taken
daily for approximately 10 days at which time the medications used to stimulate the ovaries
will be given.
Bravelle, Follistim and Menopur are the fertility drugs used to stimulate your ovaries directly.
They are pure hormones that are identical to those you make on your own. You usually begin
these medications after 10 days of Lupron therapy (usually around day 2-3 of your period).
These medications are also subcutaneous injections and will usually be taken for 8-10 days.
We will retrieve (aspirate) the eggs before you would naturally ovulate and release them.
Major side effects from these medications are very rare. The most common side effects
experienced while on Lupron are occasional hot flashes. These occur for usually only a short
period of time. Side effects from the other medications include mood swings, fatigue and
irritability. In addition, hyperstimulation of your ovaries is a risk that can cause abdominal
discomfort. Less than 1-2% of women will have a severe case of hyperstimulation. You are
closely monitored so that potential side effects can be avoided.
To confirm that egg development is proceeding satisfactorily in the ovary, and to predict
when ovulation is to occur, you will have frequent ultrasound examinations and blood tests
for approximately 5-7 days. The development of fluid filled sacs within the ovaries (follicles)
can be seen and measured by an ultrasound examination. Blood tests will give a measurement
of how well the eggs are developing. When optimal conditions have been attained, hCG
(human chorionic gonadotropin) is given for final egg maturation. Approximately 35 to 36
hours later, we will retrieve your eggs.
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Egg Retrieval
Egg retrieval is done by transvaginal ultrasound guided retrieval, a non-surgical outpatient
procedure. Only donors whose ovaries are accessible to transvaginal ultrasound guided
retrieval will be considered for the donor program.
The retrieval is performed in our office suite, next to the IVF laboratory. The procedure is
performed under anesthesia. The patient is sedated so that she neither feels nor remembers
the procedure. An anesthesiologist or a certified nurse anesthetist provides the anesthesia. A
vaginal probe, which is a cylindrical device with an ultrasound transducer on the tip, is
introduced into the vagina. This allows us to see the ovaries and other pelvic structures.
There is a needle guide attached to the vaginal probe that directs the aspirating needle
through the vaginal wall into the follicle. The follicle is aspirated into a test tube. Often
many follicles can be aspirated in the ovary with only one puncture.
The procedure takes approximately 30 minutes and, in most cases, you will be able to get up
shortly after the procedure, get dressed and go home. You may feel a little drowsy and will
be asked to stay in our recovery area for a period of time after the retrieval to recover and
ensure that you have no abnormal effects from the medication. Following the procedure,
most women describe a little vaginal bleeding and some lower abdominal discomfort similar
to a period for the next couple of days or so.
*Important Note: We try to retrieve all the eggs, but there may be a few that we are unable
to retrieve. For this reason, it is very important that you avoid intercourse from the
beginning of your stimulated cycle until one week after egg retrieval.
After the egg retrieval, you will have a follow-up visit with the doctor approximately one
week after your procedure. Your participation has concluded at this time and is most
appreciated and respected.
Who is an Egg Donor?
An egg donor is a woman between the ages of 21 and 32. She can be a friend, family member,
or an anonymous donor. She can be single or married and may already have children of her
own.
If you are participating in an anonymous cycle, all identifying information about you is kept
confidential from your recipient. You will not be given any information about the recipient or
the eggs that you have donated or the outcome of your cycle.
An egg donor must:
1. Be between the ages of 21 and 32 to maximize success rates and minimize risk of
chromosomal abnormalities in the resulting pregnancy.
2. Complete genetic screening and medical history screening. To minimize potential
complications, weight must fall within 20% of normal height/weight ratio.
3. Complete a satisfactory physical examination, including Pap smear.
4. Complete screening tests for infectious diseases and drug use.
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5. Satisfactorily complete psychological screening and counseling.
6. Give informed consent obtained after meeting with physician, psychologist, and third
party coordinator with respect to medications given and egg retrieval procedures.
Donor Screening
Appropriate screening of donors requires a complete history and physical examination,
detailed review of genetic and infectious diseases, including HIV, psychological evaluation
and extensive counseling regarding the risks, benefits, and alternatives to the procedure prior
to the signing of informed consent forms.
Whether the donor is anonymous or known to the recipient usually dictates the degree of
psychological screening done with any eligible donor and recipient. In anonymous donor
situations, an intake interview for the donor is scheduled with the program psychologist.
Issues are raised for the donor's (and her partner’s, if he chooses to accompany the donor)
consideration. The main focus of the interview is to educate the donor about the unique
issues raised by choosing to be a donor. The donor will have the opportunity to explore her
thoughts and feelings about being a donor, as well as her motivation, since little is known
about the feelings a woman may have about donating her eggs during or after the donation.
In a situation where a family member or friend is a donor, it is important that evaluation and
counseling explore as many potential issues as possible, and that all participants are
comfortable with the process. The interview will examine the concerns and feelings
surrounding giving birth to a child who is genetically related to the donor or a close friend.
Attitudes about how to share or not share this information with the child and/or others will
be discussed with all participants. Discussion will also focus on how relationships may be
redefined by sharing this experience. The donor and her partner will have the opportunity to
explore her thoughts and feelings about being a donor, as well as her motivation, since little
is known about the feelings a woman may have about donating her eggs during or after the
donation.
DONOR COMPENSATION
Compensation is provided through the program for time, effort, and inconvenience incurred
for all donors who enter the anonymous egg donor program. This includes compensation for
daily treatment as well as actual egg retrieval. YOU WILL NOT BE RESPONSIBLE F'OR ANY
COSTS INCURRED IN THE PROGRAM. You will however be responsible for your own
transportation.
Please be aware that if you are accepted into the program, you will be compensated for your
participation as shown below:
a. If you complete egg donation through egg retrieval you will receive $6,000 at the
Post-Op Visit (post operative to the Egg Retrieval).
b. If you complete a partial cycle, you will be compensated based on the cycle stage
that you have completed, in accordance with the schedule below:
$500 Lupron Phase up to, but not including Ovulation Induction Phase
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$1000 Ovulation Induction up to, but not including retrieval
PLEASE NOTE:
If you complete the entire cycle, your total compensation will be $6,000; however, if you
complete a partial cycle, you will be compensated according to whichever phase of the cycle
you were in at the time of cancellation. This compensation will be provided at the date of
your final follow-up visit.
Who is an Egg Recipient?
Any woman who has a uterus but has absent, non-functioning ovaries, or women with poor
egg quality including women who are menopausal or approaching menopause. There are a
wide variety of pathologic disorders that may only be treated with egg donation.
PRELIMINARY CONSULTATION AND EVALUATION
We require that all women interested in becoming an anonymous egg donor first attend a
Donor Open House. This presentation is given by the Egg Donor Coordinator. She will explain
in detail the benefits, risks, and requirements of the egg donor program. Once we have
reviewed your application and medical records we will contact you to invite you to our next
Donor Open House if you are deemed eligible for participation. This presentation is held at
the Woodstock office location only.
Once you have attended the Donor Open House, if you choose to proceed, an appointment
will be arranged at which time you will meet with various members of the IVF team. These
appointments will include the following:
1. You will be asked to complete a psychological assessment questionnaire and meet with a
psychologist in a clinical interview.
2. A clinical interview will then follow with the Egg Donor Coordinator during which there
will be a review of your reproductive history as well as an orientation to the egg donor
program. Discussion will include various procedures, medications, and schedules. This
visit will also include a brief consult with one of our physicians. At this time we will do a
complete physical exam including a pelvic exam and blood screening.
3. As part of your screening to become a donor, we will also require blood hormone testing
and a transvaginal ultrasound. This must happen during the first four days of your
menstrual cycle. The Egg Donor Coordinator will help you schedule this appropriately.
4. Lastly, we will arrange a phone consult with a genetic counselor.
The overall evaluation process is designed not only to evaluate you as a potential egg donor
but also to make this a positive experience for you. Please feel free at any point to ask any
questions.
Egg Donor Questionnaire
INSTRUCTIONS:
This questionnaire provides us with needed information to help us to evaluate you for
our Donor Egg program. Please fill it out completely. Some of this information will be
given to the recipient of your eggs, who may in turn give this information to any
children that may result from this egg donation cycle. For this reason, we ask you to
be as thorough and careful in your responses as possible. All information requested in
this questionniare will remain anonymous.
Donating eggs is a caring and generous act, despite some risk and discomfort. Our
recipients feel deep gratitude and respect for this gift that you are so willingly sharing
with them. Obviously, most recipients want to know as much as possible about the
medical history of the woman who made their family possible. We thank you for
allowing them to know you a little better.
Your identifying information such as your name, social security number, etc. will not
be shared with the egg recipient. Portions of the questionnaire and pictures of you
under the age of five may be shared with the egg recipient, but all personally
identifying information will be withheld from them.
The following guidelines may help:
1.
Please fill in all blanks completely. Write "NA" in blanks that are not applicable. If there
are any terms or phrases that do not appear familiar to you, do not ignore them. Please
make a note of them and ask about them at the time of your interview with the Third
Party Coordinator.
2.
Please be as specific as you can. Please avoid using old age for causes of death; you may
want to ask relatives what they know about family members who are less familiar to you.
List any health problems as specifically as possible.
Give ages to your best
approximation.
Thank you for your thoroughness!
ACRM
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EGG DONOR QUESTIONNAIRE
Today’s date: _____/_____/_____
PHYSICAL CHARACTERISTICS
Date of birth:
___/___/______
Place of birth: ________________________
Current height: ______________
Age adult height was reached: ___________
Current weight: ______________
Weight at age 21:
Eye color:
Blood type (if known): __________________
______________
Hair (check all that apply):
Natural hair color:
_____ Curly/wavy (naturally)
_____ Average texture
_____ Thick texture
_________________
_________________
_____ Straight (naturally)
_____ Thin texture
_____ Premature graying (at age____)
Skin color:
_____ Fair
_____ Olive
_____ Freckled
_____ Light brown
_____ Rosy
_____ Dark brown
_____ Medium
_____ Ebony
Body frame:
_____ Small
_____ Medium
_____ Large
Handedness:
_____ Right
_____ Left
_____ Ambidextrous
PERSONAL CHARACTERISTICS
Ethnic background:
_____________________
Race:
Religion born into:
_____________________
Religion practiced: __________________
Marital status: ____single
____married
____________________________
____divorced / separated
____ widowed
Duration of relationship with partner: ________________________________
Education:
______
______
______
______
______
(check all that apply)
completed grade school
completed high school
currently in trade school pursuing:
completed trade school in:
currently in college pursuing degree in:
______ completed college with degree in:
______ currently pursuing advanced, degree in:
______ advanced degree in:
(GPA = _____)
____________________
____________________
____________________
(GPA = _______)
____________________
(GPA = _______)
____________________
____________________
ACRM
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Subjects most enjoyed: ______________________________________________________________
Testing scores: SAT: __________ GRE: ___________ LSAT: ____________ MCAT: ___________
Current occupation: _________________________________________________________________
What would you like to do in the future?________________________________________________
Special interests / hobbies: ___________________________________________ _______________
____________________________________________________________________________
Talents: ____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PERSONAL HEALTH HISTORY
Vision: Are you:
________ nearsighted? __________ farsighted?
Do you wear glasses/contacts? ______ Age first wore glasses: ________
Hearing:
_____Poor
_____ Fair
_____ Good ______Excellent
Dental:
_____Poor
_____ Fair
_____ Good ______Orthodontic work
Prior Smoking:
_____ No
_____ Yes: (for how many years? _______)
Current Smoking:
_____ No
_____ Yes: (number per day _______)
Diet:
_____ Usual
_____ Vegetarian
Drinks:
_____ per day _____ per week ______ per month
Exercise:
_____ none
_____ occasional______regular
Allergies:
_____ none
_____ yes (specify below)
_____ Meds
_____ Environmental
_____ Food
_____ Other
For each allergy, describe specific substance, reaction(s) and age first noticed:
Substance
Reaction
Age
________________________________________________________________
________________________________________________________________
________________________________________________________________
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Blood transfusion?
______No
_____ Yes: (when and why:
__________________________)
X-rays?
______No
_____ Yes: (when and why:
__________________________)
Radiation exposure?
______No
_____ Yes: (when and why:
__________________________)
Surgery?
______No
_____ Yes: (when and which:
__________________________)
Hospitalized?
______No
_____ Yes: (when and why:
__________________________)
Major illnesses?
______No
_____ Yes: (when and which:
__________________________)
List any medications (prescribed or over-the-counter) that you are currently taking:
________________________________________________________________
________________________________________________________________
________________________________________________________________
REPRODUCTIVE HISTORY
Age at first period/menses:
____________
Average length of cycle (from 1st day of period to start of next period):
____________
Number of pregnancies in total:
____________
Number of miscarriages:
____________
Number of abortions:
____________
Number of tubal pregnancies (ectopic):
____________
Number of children:
____________
Their ages and health: ____________________________________________________________
________________________________________________________________________________
Did you ever have trouble conceiving:
_______ No
______ Yes
Have you ever had irregular cycles:
_______ No
______ Yes
Describe any treatment (s) for this you’ve had: _________________________________________
__________________________________________________________________________________
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FAMILY HISTORY
Are you adopted?
_______ No
______ Yes
How many blood siblings are in your family?
______males
_____females
Please describe your family members by the following characteristics:
Age
Eye
color
Hair
color
Height
Weight
Weight
(age 21)
(current)
Ethnic Origin
If deceased, the
cause:
Mother
Father
Brothers:
123Sisters:
123Paternal
Grandfather
Paternal
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Have twins or multiple births occurred in your family?
_______ No
______ Yes
Do you have any African ancestors?
_______ No
______ Yes
_______ No
______ Yes
_______ No
______ Yes
_______ No
______ Yes
_______ No
______ Yes
_______ No
______ Yes
If yes, have you been tested as a carrier of sickle cell disease?
If yes, result: _____________________________________
Do you have any Asian, Greek or Italian ancestors?
If yes, have you been tested as a carrier of Thalassemia?
If yes, result: _____________________________________
Do you have any Jewish ancestors?
If yes, have you been tested forTay Sachs or Gaucher’ disease?
If yes, result: _____________________________________
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Please indicate which of these medical problems have occurred in your family (and the
age they first occurred if you can).
Key:
MGM
MGF
PGM
PGF
=
=
=
=
Type of problem
Blood Problems:
Anemia
Sickle-cell anemia
Hemophilia/ bleeding
disorder
Leukemia
HIV virus
Lymphoma
Other blood disorder
Cancers:
Breast
Colon
Intestinal
Lung
Ovarian
Prostate
Skin
Stomach
Testicular
Thyroid
Any other cancer?
Birth Defects:
Cleft lip/palate
Heart defect
maternal grandmother
maternal grandfather
paternal grandmother
paternal grandfather
You
Your
children
Mother
Father
Siblings
Grandparents
Aunt /
Uncle
Cousins
ACRM
Type of problem
Hip problems
Club feet
Down’s syndrome
(trisomy 21)
Other
Gastro-intestinal
Ulcers
Gall stones
Hepatitis A, B, or C
Cirrhosis
Other liver disease
Colitis
Ulcerative Colitis
Crohn’s Disease
Pyloric stenosis
Rectal disorder
Any other problem of
digestive system?
Genital /
Reproductive
Lumps or cysts in
breasts
Breast surgery
Undescended testicle
Premature
menopause
Miscarriages
Stillborn
Death of a newborn
infant
Neonatal jaundice
Other problems:
Heart problems:
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You
Your
children
Mother
Father
Siblings
Grandparents
Aunt /
Uncle
Cousins
ACRM
Type of problem
Stroke
Heart attack
Heart disease
Hardening of the
arteries
High blood pressure
High cholesterol level
Other:
Mental health
Schizophrenia
Anxiety/panic attacks
Manic Depression or
Bipolar Disorder
Depression
Hyperactivity or
attention deficit
disorder
Eating disorders
(anorexia or bulimia)
Alcoholism
Drug Abuse
Any other mental
health problem
Metabolic /
Endocrine
Diabetes
Hypoglycemia
Thyroid disease
Goiter
Adrenal problems
Musculo-Skeletal
Muscular dystrophy
Loss of muscle
coordination
Lupus
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You
Your
children
Mother
Father
Siblings
Grandparents
Aunt /
Uncle
Cousins
ACRM
Type of problem
Osteoporosis
Dwarfism
Arthritis
Scoliosis
Gout
Other diseases of
muscle/bone/joints
Neurological
Migraines
Mental retardation
Senility before age 50
Multiple Sclerosis
Cerebral palsy
Epilepsy/seizures
Hydrocephalus
Spina bifida / Neural
tube defects
Huntington’s disease
Parkinson’s disease
Tourette’s Syndrome
Other diseases of
nervous system
Pulmonary
Hayfever /
environmental allergy
Asthma
Pneumonia
Cystic fibrosis
Other lung disease
Sight / Sound /
Smell
Deafness before age
60
Cataracts before age
50
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You
Your
children
Mother
Father
Siblings
Grandparents
Aunt /
Uncle
Cousins
ACRM
Type of problem
Blindness
Color blindness
Glaucoma
Any other disorder
sight/sound/smell:
Skin
Acne
Eczema
Psoriasis
Pigmentation
disorders
Neurofibromatosis
Any other disorders of
the skin:
Chromosomal
Abnormalities
Turner’s Syndrome
Klinefelter’s
Syndrome
Urinary
Kidney disease
Other disease of
urinary tract:
Other
Any autoimmune
disorder:
Learning disabilities
or learning styles
Any other genetic
problems:
Any other condition
not mentioned
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You
Your
children
Mother
Father
Siblings
Grandparents
Aunt /
Uncle
Cousins
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SUPPLEMENTARY QUESTIONNAIRE
(This Information is not shared with Recipient)
Name ________________________________________________________________
How were you referred to the Egg Donor Program? ___________________________________________
Years employed at present job? __________
Annual income: _______________
Have you been a cell or tissue donor before?
______ No ______ Yes
If yes, indicate what type (e.g. egg, blood, bone marrow, etc.) and when:
________________________________________________________________________
Marital History (if applicable)
Date of current marriage: _________________________________________________
Date(s) of previous marriage(s):____________________________________________
Date(s) of divorce(s):_____________________________________________________
Reproductive History
Have you ever been diagnosed as having AIDS or AIDS related complex? ________ No
________ Yes
Have you or any of your sexual partners had:
Self
Partner
When?
NGU (non-gonococcal urethritis)
Syphilis
Gonorrhea
Chlamydia
Venereal Warts (HPV)
Herpes
Hepatitis
Use of IV drugs
Current method of contraception used? ______________________ For how long? __________________
List previous methods of contraception: ____________________________________________________
Number of sex partners in the last 12 months:
__________________________
My sex partner(s) has had other sex partners in the last 6 months: ____Yes ____No ____ Don’t know
My sexual orientation:
____ heterosexual
____ homosexual ____ bisexual
ACRM
Page 12
Military Service/Travel History
Yes
No
In the past 3 years, have you been outside the United States or
Canada?
If Yes: Where?
When?
How Long?
Since 1980, have you ever lived in or traveled to Europe?
If Yes to above question:
•
Between 1980 and 1996 did you spend time that adds up to
3 months or more in the UK?
•
Since 1980 have you received a transfusion of blood,
platelets, plasma, cryoprecipitate, or granulocytes in the
UK?
Were you born, or have you lived in or traveled to any African
country, including Cameroon, Central Africa, Chad, Congo,
Equatorial Guinea, Gabon, Niger, or Nigeria since 1977?
If Yes to above question:
•
When you were in _______________(African country), did
you receive a blood transfusion or any other medical
treatment with a blood-based product?
Have you had sexual contact with anyone who was born in or lived
in any African country, including Cameroon, Central Africa, Chad,
Congo, Equatorial Guinea, Gabon, Niger, or Nigeria since 1977?
From 1980 through 1996, were you a member of the US military, a
civilian military employee, or a dependant of the US military?
If Yes to above question:
•
Did you spend a total of time of 6 months or more
associated with a military based in any of the following
countries: Belgium, The Netherlands, Germany, Spain,
Portugal, Turkey, Italy, or Greece?
Counseling History
Have you ever been hospitalized for substance abuse, depression, or other psychological problem?
______ No ______ Yes
Dates
Diagnosis/Reason
Have you ever been in counseling or psychotherapy?
Dates
Diagnosis/Reason
______ No ______ Yes
ACRM
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Have you ever taken psychotropic medications (e.g. antidepressants, anti-anxiety, antipsychotic, etc.)?
______ No ______ Yes
If yes, please list medication and dates taken: ___________________________________________
Have you had any personal experience with a traumatic event?
Event
Serious accident
Rape or sexual assault
Incest, sexual or physical abuse
Victim of any crime
Other
______ No ______ Yes
Description
Exposures
Which of these have you been exposed to?
Exposed to
Toxic Chemicals
Toxic Sprays
Fumes/Exhaust
Radiation
Insecticides
Lead
Asbestos
Cleaning Solutions
When?
Extent?
Frequency
When (year)?
Which of these have you used?
Substance
Alcohol
Marijuana
Cocaine
Tobacco
Caffeine
Other recreational drugs
Do you have any body tattoos or piercings?
Area Tatooed or Pierced
When?
______No _______ Yes
Infection?
ACRM
Page 14
Work History
List jobs held in the past five years:
Job
Year Began
Employment
Year Ended
Employment
1-2-3-4--
Legal History
Have you ever been arrested or convicted of any crime (other than minor traffic offenses):
_______No ______Yes
Have you ever had children removed from your custody:
_______No ______Yes
If yes, explain: _____________________________________________________________
Are you currently involved in any lawsuits?
_______No ______Yes
If yes, explain: ______________________________________________________________
Questions about being an Egg Donor
How would you describe yourself?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What helped you to decide to become an egg donor?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What do you hope to achieve by your volunteering in the egg donor program (e.g. emotionally,
financially, etc.)?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ACRM
Page 15
What are the three most important characteristics to you that the recipient parent(s) possess (e.g.
health, religion, race, appearance, intelligence, personality, financial ability, family background,
etc.)?
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
What do you think is the biggest stress in your life at the present?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What is a typical week like for you?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
If you have discussed your intentions about becoming an egg donor, what were their reactions?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How do you think you will feel about knowing if a baby was conceived from your donation?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Describe the person for whom you would like to donate:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What do you anticipate your feelings and reactions will be to becoming an egg donor? What difficulties
do you anticipate?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Thank you for taking the time to complete this questionnaire. We will contact you
after reviewing it and receiving the rest of your paperwork.
Privacy Considerations in Third Party
Assisted Reproductive Technology
While privacy considerations are laudable and desirable generally in the practice of medicine and in
the treatment of patients, in the arena of Third Party Assisted Reproductive Technology (hereafter
“Third Party A.R.T.”), these considerations must be tempered with the necessary disclosure of
essential information to those who are involved in the process, so that those recipients of information
can utilize the disclosed information in making truly informed decisions. For the purposes under this
Agreement, Third Party A.R.T. encompasses the utilization of a donated gamete from a third party,
including sperm, egg, and embryo donation, and the term also encompasses a third party becoming
pregnant with the expectation that the child or children upon birth shall be surrendered to other
intended parents who intend to raise the child as their own, in what is known as gestational surrogacy
(where the intended parents are the genetic parents of the expected children), artificial
insemination/traditional surrogacy (where the surrogate is inseminated with the sperm of the genetic
and intended father, and the surrogate is in fact the genetic mother of the expected children), and
donor surrogacy (where a surrogate is impregnated through use of a donated egg and possibly sperm
from sources other than the intended parents).
In Third Party A.R.T., information must be exchanged in order that the involved parties can make
informed decisions on the following, and other issues:
1) The possibility of transmission of infectious disease through donation and use of gametes;
2) The possibility of genetic disease or condition through donation and use of the gametes;
3) The compliance (or lack of compliance) with medical and clinical instructions by a party
involved in a Third Party A.R.T. situation; and
4) The psychological history and profile of a party involved in a Third Party A.R.T. situation.
As Third Party A.R.T is a collaborative venture, customary notions of medical privacy do not extend to
the exchange of information among the medical practitioners and the donors, genetic and/or intended
parents, and/or surrogates. Therefore, the parties expressly waive any privacy standards or precepts
which would prevent the free flow of necessary information among them, including, but not limited to,
diagnostic tests and histories provided by the participants relating to matching, psychological
evaluations and provided histories, sexually transmitted disease, genetics, medical and physiological
suitability of the participants and/or the donated gametes, as well as the performance and results of
the participants in the course of the medical and infertility treatments.
The parties specifically waive any rights to privacy which they have or might have under any applicable
law, including but not limited to, O.C.G.A. §§ 24-9-40, 24-9-47, 31-12-2, 31-17-2, and 31-17-6, and
under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, as
interpreted under 45 CFR Parts 160 and 164 and Standards for Privacy of Individually Identifiable
Health Information, as the parties acknowledge that such disclosure is for health treatment purposes
and will be limited to those who are either providing medical or infertility treatment, or who will be
making decisions concerning the use and application of A.R.T. Information may be used for research
purposes, but the parties’ identities shall not be disclosed; Psychotherapy notes shall not be disclosed;
provided information shall not be used for marketing purposes; and this consent may be revoked at any
time, by any party’s providing such revocation in writing to the other parties and to ACRM.
Signature
Date
Notary Signature and Seal
Date
Consent for Genetic Testing and
Release of Information
I give permission for Atlanta Center for Reproductive Medicine (ACRM) and its staff to collect
blood specimens from me in order to perform appropriate lab tests to determine my status as
a carrier of genetic diseases as applicable to my ethnic background. I agree to any testing
required or suggested by the American Society of Reproductive Medicine (ASRM) and the
American Association of Tissue Banks (AATB). I also agree to any further testing of my
genetics as requested by ACRM.
I have been advised that the procedure involves the withdrawal by needle of a small amount
of blood for laboratory testing. In general, the blood sample will be sent to a reference
laboratory where the test will be performed and the results released to ACRM. I understand
that my physician will discuss my test results with me and provide for follow- up counseling
and referral to support services if necessary. I understand that a positive test result does
NOT mean that I necessarily have the genetic disease, but that I may only be a carrier of the
disease.
I understand and consent to the release of my genetic testing results and my family health
history form to the genetic services employed by ACRM for the genetic evaluation and
interpretation of my family health history and these test results. I agree to an interview with
the genetic counselor assigned my family profile. I understand this interview will be
conducted via a telephone conversation that will be scheduled between the genetic counselor
and myself to ensure the counselor has no further questions pertaining to my family health
history form. I understand that if the genetic counselor requests additional genetic testing, I
will be required to have further genetic testing before beginning the donor program. I
consent to further genetic testing, as requested by the genetic counselor and performed by
ACRM, and agree to the release of my family health history form to the employed genetic
services for interpretation and evaluation of my family health history form and the production
of a family pedigree.
I understand that the results of all my genetic testing, along with the written genetic
evaluation of my family health history and pedigree will be recorded in my medical record
and persons involved in my health care will have access to the results. I understand that the
genetic evaluations of family health history and family pedigree are considered confidential. I
understand that these test results and / or evaluations in my health record shall not be
released without my written permission except to individuals and/or organizations that have
been given access, by law, who are also required to keep my health record information
confidential.
These test results can be given out over the phone. These results cannot be left on voicemail
or a message machine. A member of the ACRM staff will call, or I may call ACRM, Monday
thru Friday from 8:00am to 4:30pm to discuss my genetic evaluation. I understand and agree
to the release of my genetic testing results and evaluations / pedigree to the recipients for
whom I shall be collecting reproductive tissue samples. I understand that if I am an
anonymous donor, my identity shall remain confidential to both the recipient and the genetic
services employed by ACRM.
Page 2
I agree to inform ACRM, in writing, if there are any changes in my genetic history, or new
developments related to genetic evaluation of my family history.
I have been informed that ASRM, AATB, and ACRM require genetic testing as related to my
ethnic background. I understand that if I decline genetic testing and interpretation, my
participation in the donor program will be impeded.
Furthermore, some laboratory
procedures may not be able to be carried out if I decline permission for this. If I do NOT
consent to the required genetic evaluation, I agree to withdrawal my status as a potential
donor in the donor program, unless I am a family member of the recipient or proposed
parent(s). I agree not to hold ACRM, my physicians, or any other personnel responsible for
any adverse results that may arise from my refusal to consent to the genetic evaluation.
By my signature below, I acknowledge:
1.
I have had all my questions answered to my satisfaction.
2.
I have been given the opportunity to refuse this test.
3.
I consent to the performance of this test.
4.
I consent to the release and use of the test results as set forth above.
_____________________________________
Patient’s Signature
__________________________
Date
_____________________________________
Patient’s Name
__________________________
Witness
I refuse to have the genetic evaluation:
_____________________________________
Patient’s Signature
__________________________
Date
_____________________________________
Patient’s Name
__________________________
Witness
Lisa A. Hasty, MD, FACOG
André L. Denis, MD, MPH FACOG
Jim Toner, MD, PhD, FACOG
Sue Ellen Carpenter, MD, FACOG
Robin Fogle, MD, FACOG
David L. Keenan, MD, FACOG
Reproductive Endocrinology and Infertility
(770) 928-2276
fax (770) 592-2092
email: [email protected]
Chad A. Johnson, PhD, HCLD
www.atlantainfertility.com
Reproductive Studies Laboratory Director
Steven A. Voelkel, PhD,
HCLD
Director of Research
Steven C. Gerson, CPA, MPAcc
Chief Financial Officer
**You must mail this form to your physician. We are unable to mail it for you. Thanks!**
(If we receive this, it will delay processing of your application)
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL AND PRIVILEGED INFORMATION
This information may include copies of any/all of the following: medical records, X-ray and laboratory
results.
Patient Name
I Authorize:
Date of Birth
Social Security Number
Name
Street Address
City
State
Zip
To Release My Medical Records To:
Atlanta Center for Reproductive Medicine
Name
100 Stone Forest Drive, Suite 300
Street Address
Woodstock,
City
GA
State
30189__
Zip
I understand this consent may be revoked at any time except due to the extent any action has already
been taken in reliance on this consent.
This facility, its employees and officers are released from legal responsibility or liability for the release
of the above information.
Patient/Legal Representation Signature
Date
5909 Peachtree Dunwoody Road, Suite720, Atlanta, GA 30328
35 Collier Road, Suite M -125, Atlanta, GA 30309
6470 East Johns Crossing, Duluth, GA 30097
100 Stone Forest Drive, Suite 300, Woodstock, GA 30189