GENESIS FERTILITY CENTRE
Suite 300-1367 West Broadway, Vancouver, B.C., V6H 4A7
Tel: 604-879-3032 Fax: 604-875-1432
www.genesis-fertility.com
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CONSENT TO THE USE OF MY SPERM AND IN VITRO EMBRYOS
Before you complete this form, be certain that you have the information regarding the use of your reproductive material
(sperm) and embryo(s) and have signed an acknowledgement that you have been informed about your options.
1. Consent to the use of your reproductive material (sperm).
Enter “Yes” or “No”
With respect to my sperm, I consent to
i) the use of my sperm in my spouse/partner’s treatment.
ii) using my sperm for creating an in vitro embryo(s) during an IVF and/or ICSI treatment cycle.
iii) using my sperm (in excess of what is needed for my treatment) for teaching or quality assurance for
assisted reproductive procedures including laboratory and clinical procedures. (Of note, no further
consent is required for the use stated above.)
iv) using my sperm (in excess of my own reproductive needs) for research. (Please note, a specific
consent outlining the goal(s) of the research is required to be signed in addition to this consent prior to the
use of the sperm for research.)
2. Consent for the use of embryos created with your sperm. (Please note, for the following options to be valid both
you and your partner need to have written “yes” beside the statement in your individual consents.)
Enter “Yes” or “No”
With respect to the embryo(s) created with my sperm, I consent to
i) using embryo(s) created with my sperm in my spouse/partner’s IVF and/or ICSI treatment cycle.
ii) the procedure of Assisted Embryo Hatching to be carried out on my embryo(s) if deemed necessary by
my physician.
iii) culture (growth) of embryos to the blastocyst stage in the laboratory.
iv) using my frozen embryo(s) (in excess of what is needed for my own reproductive treatment) for
teaching or quality assurance in assisted reproductive procedures, including laboratory or clinical
procedures should both partners decide they have no further use for the embryo(s). (Of note, no further
consent is required for the use stated above.)
v) the embryo(s) created with my sperm (that are in excess of our reproductive needs) being used by a 3rd
party. (Please note, an additional specific consent regarding donation and designation will need to be
signed at a future date.)
vi) using the embryo(s) created with my sperm (that are in excess of my own reproductive needs) for
research. (Please note, a specific consent outlining the goal(s) of the research is required to be signed in
addition to this consent prior to the use of the embryos for research.)
Consent for use of sperm and embryos
Final Aug 26 2008
3. Consent to cryopreservation & storage of (a) sperm and/or (b) embryos created from your sperm
Enter “Yes” or “No”
I consent to:
a) the storage of my sperm. (If your sperm is not going to be cryopreserved, please enter N/A)
b) the storage of embryo(s) created with my sperm.
(To keep embryos in storage, each person providing the reproductive material to create an embryo must
consent. Please be aware that either partner can change or withdraw consent to the storage of embryos at
any time. In the event that consent is withdrawn, the embryos must be thawed and discarded.)
4. Consent to the storage and use of your sperm and embryos created with your sperm in the event of your death
or in the event that you lose the ability to decide for yourself (as defined under the Health Care Consent and Care
Facility Admission Act of British Columbia).
Enter “Yes” or “No”
If I should lose the ability to decide for myself (incapacity) or in the event of my death, I consent to
Incapacity Death
i) the sperm and/or embryo(s) created from my sperm remaining in storage (If you have
said NO to both options, you do not have to complete the rest of this section.)
ii) my sperm and/or embryo(s) created from my sperm being used in my partner’s treatment.
iii) embryo(s) created from my sperm being used in the treatment of a 3rd party.(Please note: your
partner will be required to complete another consent regarding donation and designation at time of
donation.)
iv) my sperm and/or the embryo(s) created from my sperm being used for teaching or quality
assurance in assisted reproductive procedures including laboratory and clinical procedures
v) embryo(s) created with my sperm being used in a specific research project. (A separate consent
stating the goal(s) of the research must be signed. For example, embryos will not be used in stem
cell research projects unless you have given separate consent to this. Embryos can only be used
for research if your partner has also given her consent.)
5. Please be aware that this signed document will serve as your consent for all treatments (current and future) at
Genesis Fertility Centre. You will only need to sign a new consent if you wish to withdraw and/or change any part
of this document. You can change or withdraw your consent at any time except in the case when your
reproductive material (sperm) has already been used to create an in vitro embryo (s) or has already been
designated for use by a 3rd party.
My spouse/ partner is:___________________________________________
Our current address:__________________________________________________________
I understand and acknowledge that my spouse/partner and I currently live together at the above address.
_____________________________________
Print name of Sperm Donor
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Signature of Sperm Donor
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GFC Witness Printed Name
_____________________________________
GFC Witness Signature
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Date (day/month/year)
Consent for use of sperm and embryos
Final Aug 26 2008