Embryo Donation
Pre-IVF
Planning Packet
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-IVF 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
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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.
_________________________
_________________________
NotaryPublic 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.
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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.
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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.
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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
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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.
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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.
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Profile/Bio
Name:
_____________________________________________
A complete Profile/Bio contains the following information to
assist E.A. with your match:
Female
Male
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Donor Egg
Biological
Donor Sperm
Biological
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- Marital Status
Marital Status - Height and Weight
Height and Weight - Hair and Eye Color Hair
and Eye Color - Age (at
time of IVF)
Age
(at time of IVF) - Number of Children and How Conceived
Number of Children and How Conceived
e.g., number of years TTC,
AI, IVF, etc. - Ethnic Background
Ethnic Background - Religious Background
Religious Background - Level of Education
Level of Education - Hobbies and Interests
Hobbies and Interests
Career(s) Career(s) - Additional details setting you apart:
- 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:
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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
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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
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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.)