University of Colorado Denver

GESTATIONAL CARRIER/SURROGACY
ASSISTED REPRODUCTIVE TECHNOLOGIES
PATIENT CHECKLIST

Please be sure all of the following checked requirements are met before you are scheduled to start your IVF stimulation protocol. We aim to provide the best possible service but will be unable to initiate any gestational carrier/surrogacy cycle unless all the necessary steps are taken. If you have any questions regarding any aspect of your particular protocol, do not hesitate to ask. (This list is 2 pages.)

    _____Initial blood work
    For the female partner (if they are the oocyte source):OB panel (rubella immune status, CBC, type and screen, VDRL, varicella titer), TSH, Prolactin, HIV and Hepatitis panel (Hepatitis B surface- Ag, Hepatitis B core Ab-IgM, Hepatitis C Ab) An FSH and estradiol done on cycle day three within the past six months
    If African American ancestry:Sickle prep
    If Jewish ancestry:Tay Sach's screen, Canavan's Disease screen
    For the male partner:HIV and Hepatitis panel
    For the surrogate/ gestational carrier:OB panel, HIV, Hepatitis panel, CMV IgG and IgM, PAP smear

    _____ Fluid contrast ultrasound (hysterosonogram) or hysteroscopy within the past year for the gestational carrier/surrogate.

    _____ Semen analysis on the male partner done at the University of Colorado Health Sciences Center. If more than six months has elapsed since the last evaluation, we will need to repeat the semen analysis.

    _____ Call the IVF nursing staff at 720-848-1690 at the start of each menses for two cycles preceding the month you plan to do the cycle. The month prior to your anticipated start verify the stimulation protocol you or the surrogate will be using. We will need the menses of both the female partner and surrogate/gestational carrier.

    _____ IVF physical exam. Arrange an appointment for the physical exam for both the female partner and the gestational carrier/surrogate. You can call the office at 720-848-1690 to set up these exams. These exams should be done preferably two months prior to your anticipated cycle start. Additionally, a repeat exam will be required if it has been more than six months since your last IVF physical exam. At this exam a practice embryo transfer will be performed and cervical cultures will be performed on the gestational carrier. A Pap smear on the gestational carrier will also be collected if we do not have a recent copy of one on the chart. For those women over 38 years a screening mammogram with in one year of the anticipated start will be required. Please make arrangements to have this done through your primary care provider and fax the results to our office.

    _____ Financial counseling. Please contact Marie Pietroboni at 720-848-1759 to make financial arrangements for your cycle. Payment will be due in full prior to the start of the IVF medications. You will also need to sign the financial arrangement form and give to Ms. Pietroboni. Those patients using donor oocytes must pay the $500 fee to reserve their oocyte donor prior to receiving cycle dates.

    _____ Permits and consents. These include your consents for IVF-ET or GIFT and if applicable, cryopreservation of embryos (embryo freezing), ICSI, and assisted hatching. Once your consent forms are turned in your cycle will be scheduled. Patients will not receive dates to initiate drugs until these consents are received. If you do not sign these consents at our facility they must be notarized. We also must have a letter from a lawyer stating that a surrogacy/gestational carrier contract is in effect addressing the issues below:

    1. Medical insurance for the surrogate for the pregnancy, IVF procedure and IVF or pregnancy complications
    2. Surrogate's/gestational carrier's responsibilities and expected health behaviors during pregnancy and the IVF process
    3. Possible use of amniocentesis and/or pregnancy termination for an abnormal child
    4. The birth of an infant with an abnormality
    5. Visitation of child after delivery
    6. Death or divorce of intended parents before cycle/pregnancy completion.
    7. Management of the in vitro fertilization cycle (number of embryos to transfer, multifetal pregnancy reduction). Keep in mind we will not transfer more embryos then recommended by ASRM guidelines to the surrogate/gestational carrier.
    8. Laws regarding surrogacy/gestational carrier in the state the child is to be delivered.
    9. Describe the different relationships involved in this particular case (i.e. who are the sources of the genetic material: oocyte source and sperm source described in detail, who is the gestational carrier, who are the child rearing couple).
    10. Because of divergent interests of the gestational carrier and recipient couple the parties involved must obtain independent legal counseling.

    _____ Injection teaching class. Have the gestational carrier schedule an appointment with an IVF nurse at 720.848.1690 to learn to do her injections. You will also need to arrange for an injection teaching if you will be the source of the oocytes. This class takes about one hour.

    _____ Psychological Counseling. The couple, the gestational carrier and the gestational carrier's partner (if applicable) must meet as individuals and in a group with our psychological counselors to help the surrogate/gestational carrier and the recipient couple explore the range of outcomes and possible long term effects of surrogate parenting. Additionally, to help the couple consider possible psychological risks and vulnerabilities of both parties and the prospective child in the surrogate parenting process.

Thank you for taking the time to be sure that all of the above is completed in a timely fashion. We look forward to working with you.

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University of Colorado Denver
Advanced Reproductive Medicine

Anschutz Medical Campus Office
Location: 1635 Aurora Court, Aurora, CO 80045
Mailing: PO Box 6510, Mail Stop F701, Aurora, CO 80045
Tel: 720.848.1690
Toll-free: 1.888.899.7441
Fax: 720.848.1678
Colorado Springs Office
4125 Briargate Parkway, Suite 350
Colorado Springs, CO 80920
Tel: 719.314.3333
Fax: 719.314.3344

Detailed Directions to Our Offices