Download Dear Patient - Center for Reproductive Medicine

The Ronald O. Perelman and Claudia Cohen
Center for Reproductive Medicine
Weill Greenberg Center
1305 York Avenue, 6th floor
New York, NY 10021
Telephone 646-962-2764
Fax 646-962-0359
Dear Patient:
Thank you for choosing The Ronald O. Perelman and Claudia Cohen Center for Reproductive
Medicine as your health care provider.
Please find attached the Informed Consent for Ovulation Induction/Intrauterine Insemination
(IUI). This consent document must be signed by you and, if you have a partner, your partner
prior to proceeding with the treatment cycle. Each signature must be witnessed by a third party.
Please return the consent as soon as possible by bringing it to the office, faxing it to 646-9620329 or emailing it to the following email addresses: [email protected],
[email protected] and [email protected].
Please feel free to contact the office by telephone with any questions.
Justine Witzke, MPH: 646-962-5450
Rodriq Stubbs, NP: 646-962-3276
Mitasha Joseph, RN, MPA: 646-962-3382
Sincerely,
The CRM Team
The Ronald O. Perelman and Claudia Cohen
Center for Reproductive Medicine
Informed Consent for Ovulation Induction and Intrauterine Insemination (OI/IUI)
There are several steps involved in the ovulation induction process. Medications may be used to induce the maturation of multiple
oocytes (eggs) and, during this time, blood and ultrasound (sonogram) monitoring to determine my response to these medications may
be performed. Timed intercourse (TI) or intrauterine insemination (IUI) may be advised, or, if the risk of multiple pregnancy is too high,
I/we may be asked to avoid pregnancy.
Ovulation Induction
A variety of medications are available for the induction of ovulation, including clomiphene citrate (e.g., Clomid, Serophene), letrozole
(Femara), human menopausal gonadotropins (e.g., Menopur, Repronex), follicle stimulating hormone (e.g., Gonal-F, Follistim,
Bravelle), GnRH-antagonists (e.g., Ganirelix, Cetrotide), estrogen patches (e.g., Climara, Vivelle), estrogen (e.g., Estrace) and human
chorionic gonadotropin (hCG). Some of these medications are administered orally or by trans-dermal patches. Others are given by
intramuscular or subcutaneous injection and may cause bruising and discomfort at the injection site. Clomiphene citrate may result in
side effects, including hot flashes, abdominal distention, bloating, headaches and visual changes. Gonadotropins (e.g., Repronex,
Menopur, Gonal-F, Follistim, Bravelle) may have side effects, including over-stimulation of the ovaries, leading to a condition called
Ovarian Hyperstimulation Syndrome (OHSS). In the most severe form of OHSS, serious complications may result, which may require
hospitalization and medical intervention. Reported complications, while rare, include ovarian torsion (twisting of the ovary), blood clots,
kidney failure, fluid overload and death. I/We, therefore, understand the importance of maintaining close contact with the staff of CRM
during the period of time I receive these medications and for a minimum of two (2) weeks afterwards. Furthermore, some studies have
suggested that fertility medications might increase the risk of developing ovarian cancer.
Monitoring Protocol
I/We understand that while receiving the medications described above, I will be closely monitored by the CRM staff through bloodwork
and ultrasound. This monitoring may be as frequent as daily and carries the risk of mild discomfort and bruising at the venipuncture
(blood draw) site. Transvaginal ultrasound examinations will be performed, as necessary, and there may be some discomfort with this
procedure. There is no apparent medical risk associated with the use of transvaginal ultrasound. I/We understand that, if monitoring
suggests poor or excessive follicular development, the cycle may need to be canceled and I will be encouraged to follow-up with my
physician. I/We also understand that, if monitoring suggests excessive follicular development, the cycle may be converted to IVF. I will
also be advised to speak with my attending physician in this scenario.
Intrauterine Insemination
I/We understand that the clinical staff of CRM may recommend an IUI procedure. An IUI involves the placement of prepared sperm
into the uterine cavity at a time indicated by the CRM staff. This may cause some cramping, discomfort and, possibly, a small amount
of bleeding. Infection is a possible risk with this procedure, which may require antibiotic treatment.
Risks
I/We understand that there is no guarantee that this treatment will result in a pregnancy. I/We understand that there is a risk of multiple
gestation (more than one baby) following ovulation induction. The risks of multiple gestation include, but are not limited to, preterm
labor and the delivery of premature infants, which may require intensive care and may have long-term complications associated with
prematurity, such as cerebral palsy, retinopathy of prematurity, chronic lung disease, lower IQ scores and behavioral problems.
I/We understand that should the treatment be unsuccessful, it may be determined that further treatment may not be indicated. I/We
also understand that I/we are financially responsible for any medical expenses incurred. I/We understand that we should refer to the
CRM Billing Department and my/our health insurance policy to determine benefits.
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I/We understand that I/we am/are advised to read the Weill Cornell Physicians Notice of Privacy Practices regarding my/our protected
health information. I/We understand that I/we may be contacted for follow-up.
I/We, by signing below, agree to proceed with ovulation induction treatment per the medical advice of my/our physician and
the CRM clinical team. I/We have been encouraged to ask questions, and agree that any questions that I/we have asked
have been answered to my/our satisfaction. I/We also understand that any future questions that I/we might have may be
answered by a member of the CRM team.
_______________________________ ________________________________ ______________
Patient Signature
Print Patient Name
Date
_______________
Date of Birth
_______________________________ ________________________________ ______________
Witness Signature
Print Witness Name
Date
_______________________________ ________________________________ ______________
Partner Signature
Print Partner Name
Date
_______________
Date of Birth
_______________________________ ________________________________ ______________
Witness Signature
Print Witness Name
Date
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