Embryo Donation

Pre-IVF

Planning Packet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

www.EmbryosAlive.com

EmbryosAlive@yahoo.com
7741 Pfeiffer Road
Cincinnati, Ohio  45242

 513-793-1593 (office)

513-518-7006 (mobile)
513-793-0052 or 727-489-2427 (fax)

 

 

 

 

Welcome to Embryos Alive, the second oldest of only two embryo adoption agencies in the United States. You were referred to our offices by your clinic prior to your invitro fertilization procedure to plan for unforeseen circumstances in the future. We hope your IVF is successful and that your dreams are fulfilled.

 

Due to the change by the FDA on May 25, 2005 there are tests you need to ask for at the time of you IVF and most importantly the required time after the embryos are created. Please tell your doctor that you want the FDA Panel for living tissue donors that is required screening so your embryos can be consider “eligible” for donation. So in the event you have remaining embryo(s) placed in storage and something happens to you the embryos would need all the screening retested and there may be no way to find you which would render the embryos “ineligible” for donation (labeled ineligible) and with a strong possibility that no exemption could be made forcing the embryos to stay in storage, be destroyed or given to research against your true desires.

 

That said, we are happy to provide pre-IVF forms and answer any questions about embryo adoption, along with the list of requirements you should ask your doctor to provide. (see page 9)  We also want to thank you for requesting information about embryo donation and your choice to give your embryo(s) a chance for life!


The documents contained in this Informational Packet will acquaint you with the steps involved in the pre-IV
F planning process, so you can prepare for future unforeseen circumstances.

If you decide you would like to proceed further, please contact us at 513-793-1593 or
e-mail us at EmbryosAlive@yahoo.com and visit us at www.EmbryosAlive.com.

 

Our staff is available to answer additional questions as well as mediate and facilitate your embryo adoption plan. Thank you in advance for giving us the chance to be a part of this potential life-giving decision.  We are excited and happy to help! Please feel free to contact us at any time.

 

Sincerely,

 

Bonnie J. Bernard

 

Bonnie J. Bernard

Bonnie J. Bernard, M.Ed.

Founder/Executive Director

 

 

 

Table of Contents

 

Welcome Letter

2

Relinquishment In The Event of Death

4

Relinquishment In The Event of Legal Incapacitation

                         5

Relinquishment In The Event of Divorce

                         6

Disclosure Statement/Contract

7

Considerations

8

Profile/Bio

9

Release of Information

10

Contact Information

 

11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMBRYO RELINQUISHMENT IN THE EVENT OF DEATH

 

In the event of both of our deaths, We, the Donor parents of certain frozen embryos, under an Embryo Adoption Agreement entered into on or about _________________20__ (hereinafter referred to as “the Agreement”), do hereby relinquish and surrender all such embryos which have not been previously thawed, consisting of ____ (   ) frozen embryos, cryogenically stored at _________________________, (name of clinic) in ___________________________ (address of clinic) so the embryo(s) may be adopted or donated by Embryos Alive or its designee for the purpose of adoption and implantation in an adoptive mother. This relinquishment shall be subject to the additional terms and conditions of the Agreement.


Any and all records including, but not limited to, profile, photographs, embryology report(s), blood laboratory testing, letter/s of eligibility, physical examination, gynecological examination and or results report(s), social or medical history of all donors, psychological evaluation(s), and/or any other documents required by the FDA or clinic may be received upon request by Embryos Alive or potential adopter clinic(s) and/or may be released to
Embryos Alive staff or its designee to assist in the match and/or adoption of said embryo(s).


Either or both of us shall have the right to rescind this relinquishment within three (3) days of the date hereof, by notifying Embryos Alive by telephone at (513) 518-7006 (between the hours of 8:30 a.m. and 5:00 p.m. Eastern Standard Time) followed by confirmation in writing delivered to Embryos Alive at 7741 Pfeiffer Road, Cincinnati, Ohio 45242, by first-class U.S. mail.

 

Genetic Parent/s:

 

                                                                                                                                   

               

_________________________________      ______________________________

(Print Genetic or Donor Parent Name)                                         (Print Genetic or Donor Parent Name)

 

State of ____________)                                                             State of _____                             )

                     ) ss                                                                                                              ) ss

County of __________ )                                                             County of ______                                            )

Subscribed and sworn before me on this ____                         Subscribed and sworn before me on this___

day of ___________, 2016.                                                        day of ___________, 2016.

 

_________________________                                _________________________

Notary Public                                                         Notary Public

My commission expires: ______                             My commission expires: ________

 

Embryos Alive, LLC 

By:________________________________________, 
Founder/Executive Director        

             Bonnie J. Bernard, M.Ed.

           
           
 State of Ohio

                 County of Hamilton

                 Subscribed and sworn to before me, this                              day of                     , 2016.

 

 

                )                                                                                                                                                                              

                )                                                                                               Notary Public

 

·         Please maintain an executed copy of this document with your will.       

 

 

EMBRYO RELINQUISHMENT IN THE EVENT OF LEGAL INCAPACITATION

 

In the event both of us are legally incapacitated, We, the Donor parents of certain frozen embryos, under an Embryo Adoption Agreement entered into on or about _________________20___ (hereinafter referred to as “the Agreement”), do hereby relinquish and surrender all such embryos,  ________ (    ) (months or years) after we have been diagnosed as legally incapacitated, which have not been previously thawed, consisting of ____ (   ) frozen embryos, cryogenically stored at _________________________, (name of clinic) in _________________________________________ (address of clinic) so the embryo(s) may be adopted or donated by Embryos Alive or its designee for the purpose of adoption and implantation in an adoptive mother. This relinquishment shall be subject to the additional terms and conditions of the Agreement.


By signing this relinquishment, we forever terminate and surrender all of our parental rights to those embryos including any and all parental rights to children born as a result of the implantation of embryos in the adopting mother after  ______ (    ) (months or years) of diagnosis of legal incapacitation.

 

Any and all records including, but not limited to, profile, photographs, embryology report(s), blood laboratory testing, letter/s of eligibility, physical examination, gynecological examination and or results report(s), social or medical history of all donors, psychological evaluation(s) and/or any other documents required by the FDA or clinic may be received upon request by Embryos Alive or potential adopter clinic(s) may be released to Embryos Alive staff or its designee to assist in the match and/or adoption of said embryo(s).

Either or both of us shall have the right to rescind this relinquishment within three (3) days of the date hereof, by notifying Embryos Alive by telephone at (513) 518-7006 (between the hours of 8:30 a.m. and 5:00 p.m. Eastern Standard Time) followed by confirmation in writing delivered to Embryos Alive at 7741 Pfeiffer Road, Cincinnati, Ohio 45242, by first-class U.S. mail.

 

Donor or Genetic Parent:

 

                                                                                                                                   

               

_________________________________                                    ______________________________

(Print Genetic or Donor Parent Name)                                         (Print Genetic or Donor Parent Name)

 

State of ____________)                                                             State of _____                             )

                     ) ss                                                                                                              ) ss

County of __________ )                                                             County of ______                                            )

Subscribed and sworn before me on this ____                         Subscribed and sworn before me on this___

day of ___________, 2016.                                                        day of ___________, 2016.

 

_________________________                                _________________________

Notary Public                                                         Notary Public

My commission expires: ______                             My commission expires: ________

 

Embryos Alive, LLC 

By:________________________________________, 
             Bonnie J. Bernard, M.Ed.

              Founder/Executive Director

       State of Ohio

         County of Hamilton                                                                        

          Subscribed and sworn to before me, this                           

          day of                    , 2016.                                                                                                                     ______________                   
                                                                                                                                                      
Notary Public

Please maintain an executed copy of this document with your will. 

 

EMBRYO RELINQUISHMENT IN THE EVENT OF DIVORCE

 

In the event of divorce,  I/We ___________________________ and_________________

______________relinquish our parental rights of any unused embryos after ___ years from the date the divorce was finalized to the embryo(s) cryogenically stored at ______________ ____________________________________ (name and address of clinic), so the embryo(s) may be matched for adoption or donated by Embryos Alive or its designee for the purpose of adoption for the purpose of adoption and implantation in an adoptive mother. This relinquishment shall be subject to the additional terms and conditions of the Agreement.


Any and all records including, but not limited to, profile, photographs, embryology report(s), blood laboratory testing, letter/s of eligibility, physical examination, gynecological examination, and or results report(s), social or medical history of all donors, psychological evaluation(s) and/or any other documents required by the FDA and/or clinic may be received upon request by Embryos Alive or potential adopter clinic(s) may be released to
Embryos Alive staff or its designee to assist in the match and adoption of said embryo(s).


Either or both of us shall have the right to rescind this relinquishment within three (3) days of the date hereof, by notifying Embryos Alive by telephone at (513) 518-7006 (between the hours of 8:30 a.m. and 5:00 p.m. Eastern Standard Time) followed by confirmation in writing delivered to Embryos Alive at 7741 Pfeiffer Road, Cincinnati, Ohio 45242, by first-class U.S. mail.

 

Genetic or Donor Parents:

 

                                                                                                                                   

               

_________________________________      ______________________________

(Print Genetic or Donor Parent Name)                                         (Print Genetic or Donor Parent Name)

 

State of ____________)                                                             State of _____                             )

                     ) ss                                                                                                              ) ss

County of __________ )                                                             County of ______                                            )

Subscribed and sworn before me on this ____                         Subscribed and sworn before me on this___

day of ___________, 2016.                                                        day of ___________, 2016.

 

_________________________                                _________________________

Notary Public                                                         Notary Public

My commission expires: ______                             My commission expires: ________

 

Embryos Alive, LLC 

By:________________________________________, 
             Bonnie J. Bernard, M.Ed.

         Founder/Executive Director
        
 State of Ohio

            County of Hamilton

            Subscribed and sworn to before me, this                               day of                     , 2016.

 

 

                )                                                                                                                                                                              

                )                                                                                               Notary Public

 

·         Please maintain an executed copy of this document with your will.       

 

 

 

 

     

 

Disclosure Statement/Contract

 


We are aware that embryo adoption is an emotional and challenging process. Sensitive issues may arise that require discussion between parties.  

 

We will come to our adoption specialist first to resolve any problems that may arise. We understand s/he will work with us to the best of his/her ability to resolve any issues or concerns. 

 

Embryos Alive cannot guarantee a perfect resolution but will do everything within its power and control to resolve any issues in our favor.

 

In the event that Embryos Alive cannot resolve an issue to our satisfaction, we understand that the staff empathizes with us and will endeavor to help us manage a difficult situation.

 

Adoptive parent(s) or their clinic may review our lab work in order to determine the viability of proceeding with the process.

 

You must request and obtain the egg and sperm donor FDA required REPEAT repeated blood lab work, letter of eligibility, physicals, and use an FDA approved lab or the embryos will be labeled ineligible for donation. (see list on separate page).

 

In the event I/we change our mind and decide not to proceed, we have 48 hours from the date we agree to a match of adoptive parent(s) to cancel in writing by certified mail sent to Embryos Alive 7741 Pfeiffer Road, Cincinnati, Ohio  45242-5020. Should donor(s) decide after the 48 hour period not to proceed, the donor(s) may be responsible for any costs incurred by adoptive parent(s) and Embryos Alive in pursuing this process.

 

 

 

_____________________________                   _____________________________

Applicant                                                                    Applicant

 

 

_____________________________                   _____________________________

Date                                                                            Date

 

 

 

 

 

 

Considerations

·         National statistics indicate a 40% chance frozen embryos will thaw.  Of those that thaw, there is a 50% chance they will attach to the lining. Vitrification process shows results of 70-95% thaw rate.

·         The adoptive couple may give birth to the sex of the child you had hoped for.

·         Caution to the anonymous option: your children could go to college, meet, and marry.

·         FDA and SART guidelines from May 25, 2005 requires that clinics obtain initial donor blood work and repeat it (allowing for an incubation period) of three (3) months after IVF.

·         Since FDA guidelines changed on May 25, 2005 if you plan to donate extra embryos they must be tested with the same process of a traditional egg or sperm donor!

·         Post May 25, 2005 all blood work must us an FDA approved laboratory (or the embryos may be rendered ineligible for donation).

·         If your Doctor does not do the additional FDA requirements your embryos will be labeled ineligible for transfer forcing them into destruction, continuous limbo of storage, and or research. 

·         If you do not obtain the additional post May 2005 FDA requirements we will hope that we can find you and obtain this blood work, physicals, letters of eligibility and any other missing lab work.  

·         If you did your IVF prior to May 2005 you do not need additional blood work and testing.

·         Cord Blood storage is an option for unforeseen possible illness of your child(ren) in the future.

·         The time it takes to match your embryos varies. We must have the embryology report from your clinic, which can take days, weeks, or months to obtain.

·         You, E.A., the adoptive parents(s), and potential little ones are pioneers. We have no idea what issues or emotions may arise in the future, but we all have the love and best interest in mind for each other, especially the little ones!

·         We have a dedicated Yahoo support group for parents who donated and children who were born:  EmbieDonorSupport-subscribe@yahoogroups.com.

·         Counseling is advised for both the donors and adoptors just like with a traditional adoption.

 

 

 

 

 

 

 

 

 

FDA May 25, 2005 Requirements
Post IVF testing and documentation

·         For more information on the FDA May 25, 2005 changes for embryos to be eligible for adoption/donation visit

·         http://www.embryosalive.com/donors.htm

·         http://www.integramed.com/inmdweb/content/cons/conceptions/new-donor-reg.jsp

·         http://www.fda.gov/cber/rules/suitdonor.pdf

·        http://www.fda.gov/cber/gdlns/tissdonor.pdf

SUMMARY  Tests currently FDA mandated include:

·         HIV 1 & 2

·         HTLV I/II

·         Hepatitis B Surface Antigen

·         Hepatitis B Core Antibody (IgG/IgM)

·         Hepatitis C Antibody

·         RPR (Syphilis)

·         CMV IgG/IgM

·         Gonorrhea/Chlamydia Culture But female donors whose eggs were removed by non- 
       vaginal laparoscopy (rather than transvaginally) are exempt from the last two
       requirements.

·         Blood Typing

·         Rh Factor

·         Review of medical history and test results

·         Physical examination

·         An interview in which an evaluation of risk factors (including high-risk social behaviors) is made. In addition, donors are also screened for risk or evidence of human transmissible spongiform encephalopathy (mad cow disease) by being asked if they have been to a risk region during a specific period of time for a specific length of time (e.g., Creutzfeldt-Jakob Disease). The list of diseases and agents that must be screened or tested for is subject to expansion in the future. 

·         Egg and sperm donors donating after May 25, 2005 must also undergo a donor eligibility determination, which automatically applies to any embryos created. (If remaining embryos are later donated, no additional testing would be required of the egg or sperm donor, although the original donor eligibility requirements for sperm donors are more extensive than for egg and embryo donors).

·         If frozen donor sperm collected prior to May 25, 2005 was used to create embryos after May 25, 2005, there is no requirement for a donor eligibility determination to be performed on the sperm donor. The majority of sperm banks have been testing and screening donors for most relevant communicable diseases for many years.

 

Profile/Bio


Name: _____________________________________________

 

A complete Profile/Bio contains the following information to assist E.A. with your match:

 


                          Female                                                                            Male
     
 Donor Egg          Biological                            Donor Sperm      Biological

 

  1. Marital Status                                                        Marital Status
  2. Height and Weight                                               Height and Weight
  3. Hair and Eye Color                                              Hair and Eye Color
  4. Age     (at time of IVF)                                  Age   (at time of IVF)
  5. Number of Children and How Conceived        Number of Children and How Conceived
    e.g., number of years
    TTC, AI, IVF, etc. 
  6. Ethnic Background                                              Ethnic Background
  7. Religious Background                                          Religious Background
  8. Level of Education                                              Level of Education
  9. Hobbies and Interests                                         Hobbies and Interests
    Career(s)                                                              Career(s)
  10. Additional details setting you apart:
  11. Level of openness desired: 

e.g., open, agency liaison, closed/anonymous

Please e-mail  jpg photos or mail

12. Any medical history

 

Type of family we would like to choose:

 

1. Open/Agency Liaison/Closed  * see our website on pros and cons of each level

2. Preferred age of couple

3. Married, Singles, or Either

4. Surrogate as some women cannot carry a child ___ yes  ___no

5. Can they already have children? (some have adopted, step, or grown children)  
    how many? _____  

6. Age range preferred:

     7.  In the event ____ or more ___ embryos remain, we would like to have two  
          families adopt.
      8. Would you consider a handicapped parent(s)  please describe:

      9.  Would you donate to parent/s from another country? ____ yes   ____  no
      9. Additional details you would like to add:

 

 

 

 

Release of Information 

I/we, ___________________________ and  _________________________, authorize Embryos Alive, Bonnie Bernard M.Ed. and/or E.A. staff to obtain, review, disseminate, and/or discuss any information related to adopting embryos with potential adoptive parent(s), clinical staff(s), or others involved with the process of adopting embryo(s) for the purpose of transferring embryo(s) donated/adopted by us.

 

 

 

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

 

 

My/our cryo storage facility, reproductive endocrinologist or  ______________________ may obtain, receive and review any and all information and/or documents regarding embryo(s) to be transferred to us from Embryos Alive, Bonnie Bernard, or a representative from Embryos Alive.

This release is good permanently from the date it is signed unless cancelled in writing.


Sincerely,



________________________                              _____________________
Signature                                                                   Date


________________________                              _____________________
Signature                                                                   Date

 

 

 

 

 

 

 

 

 

 

 

Contact Information

 

 

Embryos Alive staff or Bonnie Bernard M.Ed., Founder/Executive Director of Embryos Alive, may be reached in the following ways:

 

E-mail:  embryosalive@yahoo.com or bb@cinci.rr.com    

 

E-mails are answered days, evenings, weekends, and many holidays. If contacting after regular business hours, please allow 24 hours for a response.

 

Phone: 513-518-7006 

Fax: 513-793-0052

 

Alternate Fax: 727-489-2427
 
Mailing Address: 7741 Pfeiffer Road, Cincinnati, Ohio  45242-5020

 

Office Hours: Monday–Friday   9:30 a.m. to 4:30 p.m. (E.S.T.)