IN VITRO FERTILIZATION OR INTRACYTOPLASMIC SPERM INJECTION (IVF/ICSI) WITH EMBRYO TRANSFER AND FREEZING INFORMED CONSENT SPANISH FERTILITY SOCIETY
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1 IN VITRO FERTILIZATION OR INTRACYTOPLASMIC SPERM INJECTION (IVF/ICSI) WITH EMBRYO TRANSFER AND FREEZING INFORMED CONSENT SPANISH FERTILITY SOCIETY Ms. an adult with national I.D./passport no., marital status, and Mr. an adult with national I.D./passport no., marital status, residing in the city of, street number Postal Code Country, making this agreement as (married couple/domestic partner) I/WE DECLARE: 1) I/we have full capacity to act. 2) I/we hereby freely, knowingly and expressly give our written consent for the use of assisted reproductive technologies: With semen from the PARTNER. With semen from a DONOR. 3) Having received, prior to this act, verbal and written information, the latter through the Information Document on IVF or Intracytoplasmic Sperm Injection (IVF/ICSI), with Embryo Transfer and Embryo Freezing, which has been read, understood and signed. Accordingly, I/we have received information on the following issues: Information and advice on the techniques of assisted reproduction in their biological, legal and ethical aspects. When using donor sperm, also on its use and in particular on the legal significance of the signing of the informed consent by the husband or unmarried male in order to specify with him the paternal relationship to the offspring achieved, to be legally considered his own for all purposes. The indication, procedure, probability of success, risks, contraindications and complications of the proposed treatment and medication used. The provision of healthcare personnel to elaborate on any aspect of information that has not been sufficiently clarified. The dispositions of the possible viable embryos to be cryopreserved in the central bank due to not being transferred to the uterus in the course of treatment. Possible risks that may result from maternity at a clinically inappropriate age for both the woman during treatment and pregnancy, as well as for the offspring. The requirement to periodically renew or modify our consent with respect to the cryopreserved embryos and inform the centre of any change of address or personal circumstances that might affect their disposition (separation, death or incapacity of a spouse, etc.). Information concerning the economic conditions of treatment. 4) That, according to the medical team, for my/our reproductive plan the appropriate treatment would be the assisted reproductive technology called: IVF with and within Signature of the interested parties 1
2 the set of treatment alternatives, I/we understand that the most appropriate technique in our case is that to which we consent herein. 5) I/we acknowledge that at any time before the embryo transfer time, I/we can ask that the application of assisted reproductive technologies be suspended, and that this request must be honoured. 6) The medical team has also informed me/us of the following risks related to my/our personal circumstances:. In addition, I/we have been informed of the desirability of consulting the product leaflets of the medications prescribed to learn more about the possible risks associated with their use, without prejudice to also request further clarifications to the medical team as I/we deem appropriate. 7) I/we authorize and consent to the transfer of a maximum of (one, two or three) embryos. 8) Regarding the possibility of creating embryos that are not to be transferred to the uterus in the same cycle and based on our future reproductive plan: (check those which apply) I/we wish to generate ALL embryos possible as a consequence of the insemination or microinjection of all oocytes obtained, assuming the obligation to freeze viable embryos not transferred, and we consent to this. I/we wish to generate a LIMITED NUMBER of embryos, as a consequence of the insemination or microinjection of. (number) of oocytes, assuming the obligation to freeze viable embryos not transferred. The rest of the oocytes shall be: O Vitrified O Discarded I/we wish NONE OF THE EMBRYOS not to be transferred are generated, so that I/we authorize the insemination or microinjection of up to... (number) of oocytes. The rest of the oocytes shall be: O Vitrified O Discarded 9) That the disposition I/we wish for the potential oocytes and/or frozen pre-embryos left over would be (check all that apply): Own use, namely use by the couple, the wife or, where appropriate, the female partner. Donation for reproductive purposes (if the woman is 35 years of age). Donation for research (based on a plan duly presented and authorized by the competent health authorities, following a favourable report by the competent authority and written consent of the couple or woman). Their removal from preservation without other use at the end of the maximum retention period (when the recipient does not meet the clinically appropriate requirements for assisted reproductive technology). I/we agree to come to the clinic to formalize the renewal or reassignment of cryopreserved materials (oocytes, sperm or embryos) and assume in any case the economic cost of the material cryopreserved for as long as it is deposited in the centre. 10) I/we understand all the information that I/we consider appropriate and sufficient, provided by Dr.. 11) Likewise, in the doctor s office I/we stated: I/we do not suffer from transmissible congenital, hereditary or infectious diseases with possible serious risk to offspring. I/we have not omitted or misrepresented any data of a legal or medical nature that might affect treatment or its consequences.
3 I/we commit to notifying the centre of any changes in personal circumstances (death, separation, divorce, ). I/we promise to report any change of residence if there are frozen embryos. And once duly informed, I/WE AUTHORIZE: The application of the treatment and control procedures necessary to undergo a process of In Vitro Fertilization (IVF)/Intracytoplasmic Sperm Injection (ICSI), embryo transfer and embryo freezing if applicable. The contents of this document reflect the current state of knowledge, and therefore are subject to change if new findings or scientific progress so warrant. According to the provisions of Organic Law 15/1999, on protection of personal data, personal and health data will be recorded in a file owned by the centre. They may be used and assigned exclusively for the purposes of responsible action, enjoying the rights of access, rectification, cancellation and opposition. All data derived from the process will be reflected in the corresponding medical history, which will be kept on the premises of the institution to ensure proper conservation and recovery. NOTE: The clinic will do everything possible to maintain the storage of cells/tissues in optimal conditions but shall not be responsible for the loss of viability of the same due to natural disasters or other emergencies that are beyond the control of the clinic. Please be informed that embryos could be transferred to an alternate location in case of an emergency (floods, riots, fire, violent situations or those involving firearms, terrorist threats/attacks, gas or other explosions, earthquakes, etc.). In on the day of year Signed... Signed... National I.D. No.... National I.D. No.. Signed... National I.D. No.... (Director of the CENTRE or representative) ANNEX for the husband/partner or unmarried male: Mr., an adult, bearer of national I.D. no. hereby I consent that if I die before my reproductive material is in the womb of Ms., she may, in the 12 months following my death, become fertilized with it, and that the paternity of the child born will be mine. In on the of year Signed Dr. Physician s Signature
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5 ANNEX for VARIATION of the disposition of cryopreserved embryos Ms., an adult, bearer of national I.D./passport no. and residing on street/plaza in, Mr., an adult, bearer of national I.D./passport no. and residing on street/plaza in, Hereby request the change of disposition of our surplus/cryopreserved embryos and consent to the new disposition: O Use by the woman herself. O Donation for reproductive purposes (if the woman is 35 years). O Donation for research (based on a project presented and duly approved by the competent health authorities, following a favourable report by the competent authority and written consent of the couple or woman). O Cessation of preservation without further use once the maximum storage period has ended (when the recipient does not meet the appropriate requirements for assisted reproductive technology). I agree/we agree to come to the clinic to formalize the renewal or reassignment of cryopreserved materials (oocytes, sperm and embryos), and assume in any case the economic cost of cryopreservation for as long as it is deposited in the centre. In on the of year Signed Ms. Signed Mr. Physician s Signature:
6 ANNEX for the REVOCATION of this consent Mr./Ms., an adult, bearer of national I.D./passport no. and residing at street/plaza in, hereby requests the SUSPENSION of the application of the assisted reproductive technology to which I am submitting. Signed. Mr./Ms. Physician s signature: Signed. Mr./Ms. Physician s Signature:
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