ANDROLOGY REQUEST AND SEMEN SUBMISSION FORM
Doctor’s Name:
QFG Customer Code:
Male Family Name:
Female Family Name:
Male First Name: Female First Name:
Patient Details
/
Male Date of Birth:
/
/
Female Date of Birth:
/
Clinical Notes:
OFFICE USE ONLY
Tests Required: (cross boxes)
PATIENT TO COMPLETE
Collection Details – This section to be completed by patient
when specimen submitted:
Semen Analysis
Semen Washing for Insemination (IUI)
Date Collected:
Sperm Antibody Test
Time:
Sperm Chromatin Structure Assay (SCSA)
:
/
/
am / pm
Method of Collection:
Sperm Chromosome Studies (by FISH)
Semen Cryopreservation (freezing) for use in IVF or ICSI / IUI
Please call the team at Queensland Fertility Group on
[07] 3833 1000 to make an appointment to drop of your sample.
Masturbation
Interrupted intercourse
Seminal collection device
Time since last ejaculation or intercourse:
Specimens to be delivered within 2 hours of collection in Brisbane to:
days /
weeks
Specimens for
Semen Analysis
Semen Washing
Semen Freezing
Was any of the specimen lost during collection? Yes / No
Deliver to
Level 1, Watkins
Medical Centre,
225 Wickham Tce
Brisbane QLD 4000
Level 1, Watkins
Medical Centre,
225 Wickham Tce
Brisbane QLD 4000
Level 3, Watkins
Medical Centre,
225 Wickham Tce
Brisbane QLD 4000
Description of any loss: Minimal / Some / Half / More than half
Time
between 7am
and 11am
between 7am
and 9am
between 7am
and 10am
I certify the accompanying specimen to be a semen specimen
from the male partner named above:
NOTE: It is very important that you read the detailed semen collection
instructions to ensure the complete ejaculate is submitted for semen
analysis. If the full ejaculate is not submitted, or the integrity of the sample is
compromised in any way during transport to the QFG laboratory, there may be
a requirement for you to submit another sample.
Please complete the Submission declaration below:
Name of Person Signing:
Signed:
For Laboratory Use Only
Date test performed:
Volume:
/
/
mls
Laboratory Number:
Time Examined:
Scientist:
Technique:
INITIAL (Raw Specimen)
:
am / pm
WASHED (Final Preparation)
Sperm density
x 10 /ml
Sperm density
x 106/ml
Total motility
%
Total motility
%
Motility grades
Comments:
6
% rapid
% slow
% non-p
% immotile Motility grades
% rapid
% slow
% non-p
% immotile
Instructions for Semen Collection
Method:
• The preferred method is masturbation. If this is unacceptable,
interrupted intercourse may be used but is less desirable due to the
potential for contamination and specimen loss.
• Condoms produced for contraception should not be used as they
contain spermicides.
• Special inert condoms suitable for semen collection may be
purchased from the QFG Office. Please contact the Admin Office
[07] 3833 1000 for the current cost of these condoms.
Where?
• We prefer you to collect the specimen at home as long as you can
deliver it to the QFG Office within two hours. Alternatively you may
collect it in the semen collection room.
• In special circumstances such as collection into Tyrodes solution
for sperm antibodies and collection after retrograde ejaculation the
specimen must be collected in the semen collection room to allow
it to be analysed and processed immediately.
Container:
• A sterile plastic specimen jar, supplied by your Doctor or the QFG
Office is the only satisfactory container to use as these have been
tested for the absence of any toxic factors.
Delivery:
• The specimen should be no more than 2 hours old when it is
delivered to the QFG Office.
• Do NOT refrigerate the specimen or allow its temperature to rise
above body temperature before delivery.
• The container should be labelled with the following information:
– Your Full Name and Date of Birth & That of Your Partner
– Date & Time of Collection.
• Please complete the collection details on the front of this form
as this information enables the scientist to make appropriate
comments about the semen quality.
Collection Loss:
• It is important that the complete ejaculate is submitted for
semen analysis.
• This is not as critical for the other tests.
Specimens for Semen Analysis and/or
Sperm Chromatin Structure Assay (SCSA) and/or
Sperm Chromatin Studies (SCS)
Sexual Abstinence:
• Unless otherwise advised by your doctor, three days and
preferably not more than one week should have elapsed since
your last ejaculation.
Avoid Loss during Collection:
• Seminal fluid is composed of different fractions from the male’s
sexual accessory glands. If any of the specimen is lost during
collection (particularly the first part, which is the sperm rich
fraction), you may be requested to resubmit another complete
collection at a later date. Therefore, if the specimen you collect is
incomplete, you are encouraged to defer your test until another day.
Please ring [07] 3833 1000 and advise the reception staff that you
are deferring your test.
Results:
•Your Doctor will normally have a copy of the Semen Analysis
results within two working days.
• SCSA and SCS tests may take up to 3 weeks for results to be available. • Results are only available from your Doctor.
Booking:
• Please ring [07] 3833 1000 to make a booking at least 24 hours
before intended collection.
When?
Specimens for
Semen Analysis
Deliver to
Level 1, Watkins Medical Centre, 225 Wickham Tce
Brisbane QLD 4000
Time
between 7am and 11am
These tests will NOT be accepted on weekends and public holidays.
Semen Specimens for Washing for Insemination
Sexual Abstinence:
• Unless otherwise advised by your doctor, it is preferable that
at least two days and not more than one week should have
elapsed since your last ejaculation before semen collection for
washing and insemination.
How Long?
• The semen is briefly assessed, washed centrifugally twice with
culture medium, re-suspended in 1ml of culture medium, and then
reassessed. This may take 30-45 minutes. On busy days this
procedure may take an hour or longer.
• If the specimen is freshly collected when delivered for washing
it is necessary for us to wait until it liquefies before processing it.
This can take a further 20 minutes.
• Specimens collected into Tyrode’s solution are given three washes
taking at least 50 to 60 minutes.
When?
Specimens for
Semen Washing
Deliver to
Level 1, Watkins Medical Centre, 225 Wickham Tce
Brisbane QLD 4000
Time
between 7am and 9am
If you arrive before 7.00am please take a number from the desk and be seated until the
office staff open the Reception desk for business.
Semen Specimens for Freezing (Cryopreservation)
Sexual Abstinence:
• Unless otherwise advised by your doctor, three days and preferably
not more than one week should have elapsed since your last
ejaculation before collection of semen for cryopreservation.
Consent Forms:
• You will be required to sign a consent form authorising us to freeze
and store the semen, acknowledging that storage fees must be paid
and agreeing to keep us informed of your current address.
Booking:
• Please ring [07] 3833 1000 to make a booking at least 48 hours
before intended collection.
When?
Specimens for
Semen Freezing
Deliver to
Level 3, Watkins Medical Centre, 225 Wickham Tce
Brisbane QLD 4000
Time
between 7am and 10am
Specimens for freezing will NOT be accepted on weekends and public holidays.