Assisted Reproductive Technology Unit Department of Obstetrics and Gynaecology The Chinese University of Hong Kong The Prince of Wales Hospital Counseling for Potential Clients of RT Services Husband s name: LABEL I.D. No.: Date of birth: The above-named clients have received counseling and advice regarding their proposed Reproductive Technology treatment and the implications of this treatment. Included in this counseling was:- The implications of the RT procedure on themselves, their family and relatives, their social life, and any resulting or existing children; The financial implications of the RT procedure; Their feelings about manipulation of their own gametes or embryos outside their bodies, and the possible storage and disposal of gametes or embryos; The chances that treatment may fail; The possibility of the need of embryonic/fetal reduction; The alternative of adoption of a child; The possibilities that the implications of and feelings about their RT procedure may change as personal circumstance changes; Explanation that their particulars may be submitted to the register(s) kept by the Council in accordance with the Ordinance and its subsidiary legislation(s). That a child born from an RT procedure may apply to the Council when he/she reaches the age of 16 to check whether he/she was born in consequence of a RT procedure involving gametes or embryos not solely from his/her parents. Signature of patient (wife) Signature of husband Signature of counselor Date Date Date ART/C/Counseling/Form01E/V02/Nov 11
[p.1 of Form (7)] SAMPLE Consent to In Vitro Fertilization/Embryo Transfer To be used for every treatment cycle involving (i) fresh embryo transfer; or (ii) the use of donor gametes/embryos (whether such embryos are transferred in a fresh or frozen-thawed state) PART I PATIENT S CONSENT 1. I, of (Surname, Given s) (ID No.) (address), being lawfully married and desirous of having a child, DO HEREBY AUTHORISE (name of reproductive technology centre) (hereinafter called the Centre ), to perform the treatment of in-vitro fertilization/embryo transfer for me. 2. I also hereby consent that the Centre may proceed with the following reproductive technology procedures for me (please tick as appropriate) - ( ) in vitro fertilization & embryo transfer; ( ) pronuclear stage tubal transfer; ( ) others (please specify). 3. I consent to - (a) be prepared for egg (oocytes) retrieval including the use of drugs for hyperstimulation; (b) the removal of eggs (oocytes) from my ovaries with the aid of laparoscopy/ultrasound; (c) the administration of appropriate drugs and/or anaesthetics to me if necessary for the said procedure(s); and (d) the transfer of gametes/embryos to my body. 4. Note I consent to the mixing of the gametes of with those of. (please specify the reference no. of man who provides the sperm and woman who provides the eggs (oocytes)) 5. I understand that the donor(s) of the gamete(s)/embryo(s) shall remain anonymous* (please delete this sentence if the donation is designated). Under the Parent & Child Ordinance (Cap. 429), the donor(s) shall not be the legal parent(s) of any child(ren) born from the aforesaid treatment procedure.* (please delete the entire paragraph if no donated gamete(s)/embryo(s) are involved) 6. I acknowledge that the nature, procedures and possible complications of the treatment procedure have been explained to me by
[p.2 of Form (7)] and I have been given the opportunity to ask any question I wish. I have also been offered a suitable opportunity to take part in counselling with about the implications of the treatment procedure. 7. I fully understand and accept that - (a) the aforesaid treatment procedures may not result in a successful pregnancy; (b) I may not be able to carry the pregnancy to term; (c) I may suffer from illness(es) or complications arising out of or consequent upon a pregnancy resulting from in-vitro fertilization/embryo transfer; and (d) any child conceived or born as a result of the procedures, may suffer from defect(s) of health or mental or physical impairment(s) as a result of congenital, hereditary or other reasons, similar to the situation of a normal pregnancy. 8. I understand that the procedures as listed in para. 2 will not be performed if my husband revokes or varies his consent before the transfer of gamete(s) or embryo(s) to me. 9. I consent that unfertilised eggs (oocytes) obtained from me and/or excess embryos produced in the course of the procedures listed in para. 2 above may be (please tick one) - [ ] disposed of in accordance with the Guidelines on disposal of gametes or embryos ( the Guidelines ) in the Code of Practice on Reproductive Technology and Embryo Research published from time to time by the Council on Human Reproductive Technology. [ ] donated anonymously for the treatment of other infertile couples, in which event my gametes or embryos would not be used to produce more than a total of 1/2/3* live birth events (failing which the Centre may dispose of the stored gametes or embryos in accordance with the Guidelines). [ ] donated for research (failing which the Centre may dispose of the stored gametes or embryos in accordance with the Guidelines). [ ] donated for quality control and/or training (failing which the Centre may dispose of the stored gametes or embryos in accordance with the Guidelines). 10. I acknowledge that the Information Sheet(s) at Appendix X* (delete this appendix for cases not involving use of donor gametes/embryos) and/or Appendix XI of the Code of Practice on Reproductive Technology and Embryo Research has/have been read by me/explained to me*. I fully understand the contents of the Information Sheet(s) and I agree that my personal data and information may be used for the purposes as set out therein.
[p.3 of Form (7)] Dated the day of (Patient s Signature) (Signature of Attending Doctor) (Month) Position (Year) (in Chinese) (Signature of Witness)
[p.4 of Form (7)] PART II HUSBAND S CONSENT 11. I am (Surname, Given s) (ID No.) the husband of and I consent to the course of treatment outlined above. I understand that I will be the legal father of any child(ren) born from the treatment. 12. I understand that this consent cannot be revoked or varied once the gamete(s) or embryo(s) has/have been transferred to my wife. Any revocation or variation of this consent will not be effective until actual receipt by the Centre in writing. 13. I consent that excess embryos produced in the course of the procedures listed in the para. 2 above may be handled in accordance with my wife s instructions, as set out in para. 9 hereof. 14. I acknowledge that the Information Sheet(s) at Appendix X* (delete this appendix for cases not involving use of donor gametes/embryos) and/or Appendix XI of the Code of Practice on Reproductive Technology and Embryo Research has/have been read by me/explained to me*. I fully understand the contents of the Information Sheet(s) and I agree that my personal data and information may be used for the purposes as set out therein. Dated the day of (Month) (Year) (Husband s Signature) (in Chinese) Marriage Certificate No. * Delete whichever is inapplicable. Note: Under normal circumstances, gametes from the husband and wife should be used. The use of donated gamete(s) would be subject to proof of difficulties in obtaining normal gametes from either the husband or the wife.
HOSPITAL AUTHORITY PRINCE OF WALES HOSPITAL Department of Obstetrics and Gynaecology Information on Assisted Reproductive Procedures In-vitro fertilization (IVF) (Affix Gum Label) Reason for procedure: Infertility Stages of treatment: Ovarian Stimulation Oocyte (Egg) Collection Semen (Sperm) Collection Fertilization outside the body Embryo Transfer Nature of procedures: In-vitro fertilization (or test-tube baby) is a method of assisting couples to achieve a pregnancy which involves stimulation of the wife s ovaries to produce sufficient numbers of eggs; surgical removal of the eggs from the ovaries; collection of the husband s sperm; mixing of eggs and sperm in the laboratory for fertilization; and finally transfer of the fertilized eggs (embryos) back to the female uterus. Ovarian stimulation involves stimulation of the ovaries with hormone injections to produce sufficient numbers of eggs for the IVF process. The eggs are contained within the growing follicles. When the follicles are nearing maturity, injection is given to ripen the eggs, and the eggs are then retrieved under ultrasound guidance a little while later. Oocyte (egg) collection is performed by inserting a very fine needle into the ovary through the top of the vagina using ultrasound guidance. Follicular fluid removed through the needle is inspected under the microscope to look for eggs. The procedure takes around 20 minutes. The patient is conscious during the procedure. Pain relief and mild sedation are achieved by drugs given through an intravenous line. On the day of egg collection, the husband produces a sperm sample by masturbation. In the laboratory, the eggs and sperm are mixed together so that fertilization may occur. In some cases, sperm is injected directly into the egg to assist fertilization. A fertilized egg is called an embryo. Embryos are transferred back to the wife s uterus through the vagina using a fine tube. The procedure normally takes around 5 minutes. This procedure is painless and is done with the patient awake. Information on Assisted Reproductive Procedures In-Vitro Fertilization Risks and complications of procedures include, but are not limited, to the following: Complications related to ovarian stimulation (including ovarian hyperstimulation syndrome, ovarian torsion, thromboembolic event) Complications related to sedation (including respiratory and cardiovascular depression) Complications related to the egg collection procedure (including bleeding, pelvic infection, injury to nearby organs such as bowel and blood vessel) Multiple pregnancy (in particular if transferring more than one embryo) Ectopic pregnancy PWH 250E (01-2012) revised on 23-12-2011
The medical staff have clearly provided me with the above information and answered any questions concerning these procedures. I fully understand the procedures and queries have been satisfactorily answered. I also understand that under the Ordinance, ART treatment should be provided to persons who are parties to a marriage. I hereby state that we are lawfully married. Signature of patient (wife) Signature of husband Signature of doctor & identity number of patient (wife) & identity number of husband Date Date Date of doctor Information on Assisted Reproductive Procedures In-Vitro Fertilization PWH 250E (01-2012) revised on 23-12-2011