Sperm-Freezing Consent Form

CONSENT FORM
FOR SPERM FREEZING

Sperm samples can be frozen and stored for future use. The frozen sperm samples can be thawed in the future
and used as the sperm source for insemination treatments or in vitro fertilization.
After the sperm are exposed to cryoprotectant solutions (a special medium for freezing), they are placed in
small containers, which are cooled to subzero temperatures and stored in liquid nitrogen. At a later date, the
frozen sperm can be thawed and the cryoprotectant removed from the sperm to return them to a normal
physiological environment. At the time of sperm thawing, it is possible that no sperm will survive. Prior to
thawing the sperm sample I understand that I will need to sign a separate consent in front of a notary public
no more than 60 days before the initiation of the treatment cycle. Studies of pregnancies resulting from the
use of frozen human sperm have failed to demonstrate an increased risk of birth defects in the offspring.
However, the possibility of presently unforeseen risks cannot be completely eliminated.
As with any technique involving specialized equipment technical problems and failure may occur. Boston
IVF, its directors and employees shall not be held liable for any damage, loss or problems due to improper
freezing, maintenance, storage, withdrawal, thawing and/or delivery caused by human error, malfunction of
the storage tank, failure of utilities, strike by workers, cessation of services or other labor disturbances, any
war, acts of public enemy or other disturbances such as fire, wind, earthquake, flooding or other acts of God.
Boston IVF provides no insurance coverage, compensation plan or free medical care to compensate any
person if frozen sperm samples are harmed in any way by the cryopreservation or thawing procedures.
I understand that I will be required to pay a fee for freezing, storage, thawing and transfer of the
sperm. I understand that the fee may be increased. If there is failure to make payment for one year of sperm
storage, after reasonable notification of such non-payment mailed to my last known address as provided to
Boston IVF by me, I understand that Boston IVF reserves the right to thaw and discard the sperm.
I understand that it is my responsibility to notify Boston IVF of any change in my address or telephone
number and to provide any further information that Boston IVF may require to discharge its obligations under
this agreement.
I understand that my frozen sperm samples will be considered to be abandoned if more than one year has
passed since I have been in contact with Boston IVF in writing and, despite diligent efforts, Boston IVF is
unable to contact me at my last known address. If the frozen sperm samples are considered to be abandoned,
then Boston IVF reserves the right to remove the frozen sperm samples from storage and discard them.
If Boston IVF ceases to exist, I will be sent written notice by U.S. mail so that I can make arrangements to
have my frozen sperm samples discarded or transferred to another center for continued storage. If upon
receipt of such notice, I fail to make appropriate, timely arrangements for the discarding or transfer of my
frozen sperm samples (i.e., within six months of receipt of such notice), I understand that Boston IVF reserves
the right to remove the frozen sperm samples from storage and discard them and may do so without further
notification.
DISPOSITION OF FROZEN SPERM

In the event of my death, I wish the sperm to be:
_______________ A. Owned and controlled by the current partner who is able and willing to assume
such INITIALS ownership and control; otherwise the sperm will be discarded.
_______________ B. Thawed and discarded.

INITIALS
ACKNOWLEDGEMENT OF INFORMED CONSENT AND AUTHORIZATION
I acknowledge that I have read and fully understand this written material, and all of my questions
concerning the procedure have been fully answered to my satisfaction.
I am aware that there are other laboratories in the area that offer sperm freezing and storage and I have freely
chosen to have the service performed at Boston IVF.
I accept the responsibilities, conditions and risks involved as set out in this document and as explained to me by the
staff of Boston IVF.
I understand that before the frozen sperm samples can be thawed and used for in vitro fertilization (IVF) or
intrauterine insemination (IUI) treatment a consent needs to be signed and notarized no more that 60 days before
the initiation of the treatment cycle.
I acknowledge that it is my responsibility to notify Boston IVF in writing if I become aware of any information that
Boston IVF should have in order to discharge its obligations under this agreement.
I agree to notify BIVF immediately in writing of any change in our marital status including separation or divorce.
I acknowledge that I, the undersigned, am voluntarily freezing sperm at Boston IVF and alternatives to sperm
freezing have been explained to me.
I understand that the contact information that I have provided below is the sole information that will be used to
locate me if I lose contact with Boston IVF. I acknowledge that it is my responsibility to notify Boston IVF in
writing if I move or otherwise change my address.
By signing this document I acknowledge that Boston IVF has obtained from me informed consent to freeze sperm.
________________________________ _______________________________
Signature of Patient Signature of BIVF Witness or Notary
________________________________ _______________________________
Printed Name Printed Name of BIVF Witness or Notary
________________________________ _______________________________
Date of Birth ID Type
_______________________________ _______________________________
Telephone # ID Number and Exp Date
_______________________________
Date
_______________________(State)
On this ____day of _________________, 201___, before me, the undersigned notary public, personally appeared
_______________________, proved to me through satisfactory evidence of identification, which
were________________________________________, to be the person whose name is signed on the proceeding or
attached document in my presence.
_________________________________
Notary Public

Sperm-Freezing Consent Form

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CONSENT FORM

FOR SPERM FREEZING

DISPOSITION OF FROZEN SPERM

_______________ B. Thawed and discarded.

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