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INTRACYTOPLASMIC SPERM INJECTION (ICSI) CONSENT
I. We, __________________________________ (husband) and ___________________ (wife), hereby declare that we wish to attempt to conceive and hereby authorize the staff of Midwest Reproductive Medicine to perform Intracytoplasmic Sperm Injection (ICSI).
II. We request this procedure with a full understanding of the following:
a. ICSI is a laboratory technique performed in conjunction with either IVF or ZIFT in which highly sophisticated micro-manipulation equipment is used by the laboratory personnel to inject a single sperm into an egg.
b. ICSI is performed when prior evaluation suggests that standard insemination procedures will render less than optimal fertilization rates.
c. Following ICSI, any resulting zygotes or embryos will be treated in the standard fashion for ZIFT or IVF.
III. We understand that there are no guarantees that pregnancy will occur following transfer of embryos or zygotes following fertilization by ICSI. We further understand that although there does not seem to be any increased risk of fetal anomalies/birth defects as a result of ICSI, pregnancy complications including miscarriage and birth defects may result just as with any pregnancy. There is some concern about the possibility of an increased incidence of fertility problems in males conceived as a result of ICSI. This issue is as yet unresolved, but consideration should be give to prenatal genetic testing.
IV. We understand that the benefit to us of ICSI is an increased rate of fertilization.
V. We understand that the micro-manipulation itself, either the dissection of the cells around the egg or the insertion of the sperm may cause immediate degeneration of the egg, or yield abnormal embryos. We further understand that technical problems may arise which may make successful penetration and sperm insertion impossible.
VI. We understand that there may be some increased risk of transmission of inherited defects in sperm production/function in male infants born as a result of ICSI.
VII. We understand that there is an additional fee for ICSI. This fee is charged in addition to the usual IVF or ZIFT charges.
VIII. We understand that this consent is viewed as an addendum to the consent for IVF or ZIFT which we have executed and all conditions of that agreement apply in full to this consent.
IX. We have read and understand this consent form. We acknowledge that ICSI is being performed at our request and with our consent. We have had the opportunity to ask questions, and all questions we have asked have been answered in a satisfactory manner. We have freely and voluntarily executed this document.
Signature of
Wife:________________________________ Date:___________
Social Security Number:_______________ Date of Birth:________________
Signature of Husband:___________________________________ Date:___________
Social Security Number:__________________ Date of Birth______
Signature of Witness:___________________________________ Date:___________
Signature of Physician:__________________________________ Date:___________
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