HMH In-House Informed Consent for In Vitro Fertilization (IVF)
HMH Hospitals, Fertility and Assisted Reproductive Fertility Unit. Please complete the consent form and sign where required.
Patient Information
Female Patient Full Name
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First Name
Middle Name
Last Name
Female Patient Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Female Patient Hospital Number
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Female Patient Telephone No:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Male Partner Information
Full Name
First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hospital Number (leave blank if the same as Female patient number)
Telephone No:
Please enter a valid phone number.
Format: (000) 000-0000.
Treating Physician Information
Treating Physician Name
*
Registration Number
*
Purpose of this Consent
1. Purpose of this Consent
This document confirms that the patient (and partner, where applicable) has received information regarding IVF treatment using donor eggs, has had the opportunity to ask questions, understands the benefits, risks, limitations, alternatives, and financial implications of treatment, and voluntarily consents to proceed.
Description of Treatment
2. Description of Treatment
The proposed treatment may include: - Medical assessment - Hormonal preparation - Selection and allocation of donor oocytes, if indicated - Fertilization using partner or donor sperm - Intracytoplasmic sperm injection (ICSI), if indicated - Embryo culture - Embryo transfer - Cryopreservation of embryos where appropriate - Pregnancy testing - Follow-up care The exact treatment protocol may be modified based on clinical judgment and patient safety.
Donor Egg Information (if applicable)
3. Donor Egg Information (if applicable)
I understand that: • The eggs used will come from a medically screened donor. • Donors undergo infectious disease screening and appropriate medical evaluation. • Genetic screening may reduce but cannot eliminate the possibility of inherited disorders. • No donor can be guaranteed to produce pregnancy. • Physical characteristics of the donor may resemble my requested preferences but cannot be guaranteed. • Information provided regarding the donor may be limited in accordance with applicable laws and clinic policies.
Sperm Donor Information (if applicable)
4. Sperm Donor Information (if applicable)
I understand that: • The sperm used will come from a medically screened donor. • Donors undergo infectious disease screening and appropriate medical evaluation. • Genetic screening may reduce but cannot eliminate the possibility of inherited disorders. • No donor can be guaranteed to produce pregnancy. • Physical characteristics of the donor may resemble my requested preferences but cannot be guaranteed. • Information provided regarding the donor may be limited in accordance with applicable laws and clinic policies.
Medical Risks
5. Medical Risks
I understand that IVF treatment carries risks including but not limited to: - Medication side effects - Ovarian Hyperstimulation Syndrome (where applicable) - Infection - Bleeding - Anaesthetic complications - Ectopic pregnancy - Miscarriage - Multiple pregnancy - Premature birth - Low birth weight - Failure of fertilization - Poor embryo development - Failure of implantation - Failure to achieve pregnancy Rare complications may require emergency treatment or surgery.
Success Rates
6. Success Rates
I understand that: Pregnancy cannot be guaranteed. Live birth rates vary according to numerous factors including: - Recipient age - Uterine health - Embryo quality - Laboratory conditions - Medical history - Lifestyle factors The clinic has not guaranteed a successful pregnancy or live birth.
Alternatives Discussed
7. Alternatives Discussed
I acknowledge that alternatives have been explained, including: - IVF using my own eggs (where feasible) - Donor embryo treatment - Adoption - Remaining child-free - Choosing not to proceed with treatment
Embryo Culture and Transfer
8. Embryo Culture and Transfer
I understand that: The number of embryos transferred will be determined jointly by myself and my treating physician based on clinical judgment and applicable guidelines. Excess viable embryos may be frozen with my consent.
Cryopreservation
9. Cryopreservation
If embryos are frozen: I understand: - Storage fees may apply. - Cryopreservation does not guarantee future pregnancy. - Some embryos may not survive thawing. - I will provide instructions regarding future disposition of stored embryos.
Embryo Disposition
10. Embryo Disposition
In the event of: - Completion of treatment - Expiry of storage period - Death - Incapacity - Divorce or separation (where applicable)
I instruct the clinic as follows:
Continue storage
Discard embryos
Donate for research (where legally permitted)
Donate for reproductive treatment (where legally permitted)
Infectious Disease Testing
11. Infectious Disease Testing
I understand that I (and my partner where applicable) may be required to undergo testing including but not limited to: - HIV - Hepatitis B - Hepatitis C - Syphilis - Other clinically indicated investigations
Genetic Risk
12. Genetic Risk
Although donors undergo screening, I understand that: No medical screening can eliminate every genetic, congenital, or developmental disorder.
Legal Implications
13. Legal Implications
Legal Implications of Third-Party Reproduction (Sperm and/or Egg Donation) If donor sperm and/or donor eggs are used during treatment, we acknowledge and understand the following: 1. Parentage We understand that the child born through this treatment is intended to be our legal and social child, subject to the applicable laws of the Federal Republic of Nigeria and any relevant court orders where required. 2. Donor Rights We understand that the donor is not intended to assume any parental rights, responsibilities, custody, guardianship, inheritance rights, or financial obligations in respect of any child conceived through this treatment, except where otherwise required by law. 3. Recipient Responsibilities We accept full parental responsibility for any child born as a result of this treatment, including all legal, financial, educational, medical, and welfare responsibilities. 4. Donor Anonymity and Confidentiality We understand that, where anonymous donation is used, the identity of the donor will remain confidential except where disclosure is required by law or authorised by the donor and the Clinic. 5. Genetic Relationship a) We acknowledge that where donor sperm is used, the intended father will not be the genetic father of the child. b) We acknowledge that where donor eggs are used, the intended mother will not be the genetic mother of the child. c) We understand that the absence of a genetic relationship does not affect our intention to assume full parental responsibility for the child. 6. Birth Registration We understand that birth registration and the recording of parentage will be carried out in accordance with the applicable laws and administrative requirements in force at the time of the child's birth. 7. Inheritance and Family Rights We understand that inheritance, succession, guardianship, and other family law matters may be governed by Nigerian law and recommend obtaining independent legal advice where necessary. 8. Independent Legal Advice We acknowledge that the Clinic has advised us that legal issues relating to donor conception may change over time and that we may seek independent legal advice before proceeding with treatment. 9. Changes in the Law We understand that future legislation or court decisions may affect the legal status or consequences of donor-assisted conception, and that the Clinic cannot guarantee future legal outcomes.
Declaration
We confirm that we have read and understood the above legal implications of treatment involving donor sperm and/or donor eggs.
We have had the opportunity to ask questions and have received satisfactory explanations.
We understand that the Clinic is providing medical treatment and information only and is not providing legal advice.
Confidentiality
14. Confidentiality
The clinic will make reasonable efforts to protect my confidential medical information in accordance with applicable law and professional standards. Medical information may be disclosed where legally required.
Financial Responsibility
15. Financial Responsibility
I understand that: Treatment costs have been explained. Additional procedures may attract additional charges. Refunds are subject to clinic policy.
Withdrawal of Consent
16. Withdrawal of Consent
I understand that I may withdraw my consent before embryo transfer by notifying the clinic in writing. Withdrawal after fertilization may have legal and practical consequences which have been explained to me.
Patient Acknowledgement
17. Patient Acknowledgement
I confirm that: - I have read this document. - I understand the information provided. - I have had sufficient opportunity to ask questions. - My questions have been answered satisfactorily. - I understand the benefits, risks, alternatives, and limitations. - I consent voluntarily without coercion.
Signatures and Declarations
Patient Signature
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Patient Signature Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Partner Signature
Partner Signature Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Interpreter Name (if applicable)
Interpreter Language
Interpreter Signature
Interpreter Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician/Nurse/Counsellor Declaration Signature
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Physician/Nurse/Counsellor Declaration Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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