PRICE LIST OF THE CLINIC OF REPRODUCTIVE MEDICINE AND GYNAECOLOGY IN ZLIN This price list is valid from 25. 10. 2016 All costs for treatment do not include the cost of medication. The full payment for the treatment is due no later than on the day of patient s embryo transfer before the embryo transfer procedure. The prices for tests and examinations and any additional procedures which are not included in the package price are listed on the price list of our clinic. Deposit payment for the donor embryo program is 500, deposit payment for IVF treatment and donor egg IVF treatment is 1 000. No deposit payment applies to FET. Payment methods are: cash, debit/credit cards, bank transfer (EUR, CZK). Assisted reproduction cost Consultation with doctor 1 hour, ultrasound included If the patient decides to undergo IVF treatment, this amount will be deducted from the price of IVF treatment. NATURAL IVF CYCLE MINIMAL STIMULATION MILD IVF Consultations and ultrasounds during treatment cycle, hormone profile Tests for HIV, Hep B, C and Syphilis for both partners on egg collection day Egg retrieval under general anaesthesia Partner s sperm analysis (without ICSI) 100 950 ICSI of a single egg 50 PICSI of a single egg 60 Blastocyst culture in embryo culture media EmbryoGen or BlastGen additional fee 150 Partner s sperm cryopreservation 200 Cancelation of minimal stimulation 700 COMPLETE IVF CYCLE Consultations and ultrasounds during treatment cycle Monitoring of IVF cycle Egg retrieval under general anesthesia Partner s sperm analysis Tests for HIV, Hep B, C and Syphilis for both partners on egg collection day Fertilization using ICSI up to 10 oocytes, extended embryo culture, assisted hatching (if applicable) 1 950 F_09-2012_AMB/rev08_31-10-16_Bro Page 1 from 6
ICSI each additional oocyte (over 10) 50 PICSI in addition to ICSI (up to 10 oocytes) 180 PICSI each additional oocyte (over 10) 60 Blastocyst culture in embryo culture media EmbryoGen or BlastGen additional fee 150 IVF canceled before egg retrieval 750 IVF without fertilization, embryo transfer and cryopreservation 1 000 Partner s sperm cryopreservation 200 Vitrification of surplus quality embryos and their storage for 1 year (first 2 vials) 200 Vitrification of surplus quality embryos each additional vial 100 FRESH EGG DONATION CYCLE - fresh embryo transfer Consultation and ultrasound during treatment cycle Donor s medication, monitoring of donor s cycle, egg retrieval under general anaesthesia, donor s compensation Fertilization of all mature oocytes via ICSI Partner s sperm analysis Male partner s STD tests Vitrification of surplus quality embryos and their storage for 1 year Sperm cryopreservation and storage for 1 year (a condition of negative STD tests applies) FRESH EGG DONATION CYCLE - cryo embryo transfer Consultation Partner s sperm analysis and cryopreservation Male partner s STD tests Ultrasound during treatment cycle Donor s medication, monitoring of donor s cycle, egg retrieval under general anaesthesia, donor s compensation Fertilization of all mature oocytes using ICSI Vitrification of embryos First cryo embryo transfer included (charges apply for additional embryo transfers) FROZEN EGG DONATION CYCLE fresh embryo transfer Consultation Partner s sperm analysis Male partner s STD tests Ultrasound during treatment cycle Donor s medication, monitoring of donor s cycle, egg retrieval under general anaesthesia, donor s compensation, oocyte cryopreservation 4 500 4 000 4 000 F_09-2012_AMB/rev08_31-10-16_Bro Page 2 from 6
Fertilization of all mature oocytes using ICSI Vitrification of surplus embryos FROZEN EMBRYO TRANSFER (FET) Includes Consultation and ultrasounds during the treatment cycle Embryo preparation, extended embryo culture, assisted hatching (if applicable) 500 FROZEN EMBRYO TRANSFER DONOR EMBRYOS Includes Consultation und ultrasounds during the treatment cycle All cost related to the donors Embryo preparation, extended embryo culture, assisted hatching (if applicable) 1 embryo 2 embryos 1200 1800 We guarantee blastocyst(s) ready for transfer. OOCYTE VITRIFICATION 1 000 Consultations and ultrasounds during treatment cycle Monitoring of IVF cycle Egg retrieval under general anesthesia Egg vitrification first 2 vials storage for first 12 months is free of charge Oocyte vitrification each additional vial 100 EmbryoScope continuous embryo monitoring (12 embryos) 200 EmbryoGlue 120 Embryo or sperm cryopreservation first 2 vials 200 storage for first 12 months is free of charge Embryo or sperm cryopreservation 100 each additional vial ERA test Endometrial Receptivity Array 1 st. sample 950 ERA test Endometrial Receptivity Array - 2 st. sample 800 ERA test Endometrial Receptivity Array - 3 rd. sample 600 Donor sperm 200 F_09-2012_AMB/rev08_31-10-16_Bro Page 3 from 6
Sperm analysis 50 MACS - Magnetic Activated Cell Sorting 250 Analysis of acrosomal integrity 50 Sperm DNA fragmentation 80 Storage extension of cryopreserved embryos/oocytes/sperm for 1 year 60 Sperm or embryo or oocyte storage without STD tests (or if tested positive for STD) 1 200 storage for 12 months (100 euro per month) Import/export of sample to our clinic Individual price Import/export of sample from our clinic administration fee 100 Preimplantation genetic diagnosis - PGD PGD/PGS ARRAY CGH/NGS PGD/PGS TE BIOPSY + ARRAY CGH/NGS + CRYO 1 embryo 600 2 embryos 1 000 3 embryos 1 400 4 embryos 1 700 5 embryos 2 000 5 8 embryos 2 300 Each additional embryo 260 PGD FOR CHROMOSOME TRANSLOCATION (FISH) 1 700 PGD - PCR individual price Urological Examination Complete urological examination with ultrasound 25 Operating room Hysteroscopy (general anaesthesia not included) 400 HyCoSy 100 Curettage 60 Fetal reduction - anaesthesia included (only for clients of CRMZ) 180 Puncture of ovarian cysts under ultrasound control 50 MESA/TESE microsurgical sperm retrieval from testicle( anaesthesia not included) 600 General anaesthesia 80 Recovery room 1 day charge (other procedures than IVF or MESA/TESE) 20 F_09-2012_AMB/rev08_31-10-16_Bro Page 4 from 6
Gynaecology outpatient procedures Gynecological exam 20 Consultation with gynecologist /1 hour 40 Ultrasound 16 Colposcopy 20 Insertion of IUD (intrauterine device) 40 Removal of IUD (intrauterine device) 40 Prescription for period delay medication 20 Disposable vaginal speculum 2 Ultrasound photo 2 Vaccination 4 Intralipid infusion 100 Mammography (mammogram) 100 Breast biopsy + cytologic analysis 100 Diprophos 1 amp. 20 Dexamed 1 amp. 20 Laboratory analysis STD (sexually transmitted diseases) 80 Complete hormone profile (LH, FSH, E2, PRL, PRG, T3, T4, TSH) 50 Hormone profile : FSH, LH, E2, PRG, PRL, Testosterone 30 Thyroid panel: T3, T4, TSH, PRL 30 Hormone profile during stimulation: LH, E2, Pg 25 Pregnancy test: E2, hcg, PRG 25 AMH (Anti-Mullerian hormone) 30 Blood type test 25 Immunology test antibody test 80 Natural killer (NK) cells 55 Chlamydia trachomatis 55 Chlamydia trachomatis PCR method 45 Liver panel 20 Coagulation 20 Urinalysis + sediment ( biochemical analysis) 10 Complete blood count without differential 10 Complete blood count with differential 20 CRP ( C-reactive protein ) 25 CA 125 25 CA 19-9 25 CEA ( Carcinoembryonic Antigen ) 25 Toxoplasmosis 70 Chlamydia culture 45 Mycoplasma culture, Ureaplasma culture 35 F_09-2012_AMB/rev08_31-10-16_Bro Page 5 from 6
Cervical cytology 20 Histologic evaluation of endometrial biopsy (2 samples) 50 Thrombophillic mutations (Factor V Leiden, Factor II Prothrombin, MTHFR (C677T) 170 Thrombogene (Factor V Leiden, Factor II Prothrombin) Karyotype test 250 Cystic fibrosis 19 mutations 150 Cystic fibrosis 36 mutations + Tn 280 Y-chromosome microdeletion 150 F_09-2012_AMB/rev08_31-10-16_Bro Page 6 from 6