I/We, give________________________________ permission for all information in the assessment to be discussed with the physicians and staff at Georgia Reproductive Specialists and for the assessment to become part of my medical file.
I/We understand that this psychological evaluation may involve psychological testing and will include discussions of our psychosocial history, current mental status, current level of support from significant others, marital satisfaction, and psychological well?being. I understand that the evaluation process and the discussion of life experiences can be emotionally distressing. Psychological responses to the evaluation process may be, but are not limited to, the following: anxiety, depression, frustration/anger, distress, or disappointment, especially if it is decided either by my self or by the program that I not proceed with IVF (in vitro fertilization) as planned. Psychological risks of either the psychological evaluation and IVF (in vitro fertilization) include but are not limited to: stress, interpersonal difficulties, conflicts with loved ones, impairment in daily functioning, sexual dysfunction or distress, anxiety or panic, depression, alteration of emotional well-being or triggering of traumatic memories especially involving physical or sexual abuse/trauma.
Psychological Impact of Reproductive Technologies
Procedures involving high levels of medical technology, including assisted reproductive technologies, can be both physically and psychologically demanding. I/We understand that there are physical, psychological, and social risks involved in participating in IVF. These may include, but are not limited to:
Social and Relationship Aspects of Reproductive Technologies
- Psychological stresses of the IVF process include the stress of the evaluation, the medical procedures and future emotional reactions. Stresses of the process include managing the commitments of medical treatment, invasiveness of treatment, and stresses to relationships. Psychological risks of either the psychological evaluation or the IVF process include, but are not limited to: stress, interpersonal difficulties, conflicts with loved ones, impairment in daily functioning, sexual dysfunction or distress, anxiety or panic, depression, alteration of emotional well?being, or triggering of traumatic memories especially those involving physical or sexual abuse or trauma. In addition, I/we understand that some women experience psychological side effects to the ovulation induction medications.
- I/We have been informed that the IVF procedure itself may trigger past emotionally difficult experiences related to pregnancy, fertility, reproduction, sexuality, or family issues.
- If the procedure is not successful, I/We may respond with any number of emotional reactions including anger, disappointment, anxiety, depression, bitterness or indignation. I/We also understand that for some women, the feelings of sadness and disappointment become overwhelming and unmanageable and that I am encouraged to return for additional support and assistance should this happen to me.
- If the procedure is successful, I may feel predictable happiness and delight but also may feel disbelief and anxiety. I may feel fearful about the safety of the pregnancy or have difficulty attaching to it because of worry and fear. Furthermore, I/We understand that although IVF provides a means of becoming a parent and, as such, a means of family building, it is not a cure for infertility and I/We may continue to experience emotional distress regarding infertility even if the treatment process is successful.
- Depending upon my motivation and/or my experiences with the IVF procedure, I/We may not gain the degree of satisfaction that I/We initially expected. I/We may experience less gratification than I anticipated and the process may be less rewarding or more demanding than I/We envisioned.
- Relationship - risks as a result of the IVF (in vitro fertilization) procedure include distress in either current or future relationships with my spouse, family and friends, as well as strained social, familial or work relationships. Marital relationships may be impacted by the stresses of intense medical treatment and may result in a variety of problems such as marital conflict or transient sexual problems.
- Social - risks include conflict with religious leaders or religious doctrine or the disapproval of friends, family, or others to assisted reproduction. I/We understand that others may not understand the IVF procedure, my motivations, or my participation in assisted reproduction and I may encounter disapproval, criticism or censure. This may result in psychological distress including embarrassment, anger, resentment or distress.
Physical Impact of Reproductive Technologies
- Physical - aspects of the procedure may be psychologically demanding or stressful including injections and/or vaginal probe ultrasound. Possible health risks to me include transient physical discomfort, infection, reactions to ovulation induction medications, or currently unknown factors that may affect my physical health now or in the future. I/We have had the opportunity to discuss the health risks of IVF with the physicians and staff and feel that I/we understand them. If any risks to my health should occur, I/we could experience a variety of psychological responses including anger, regret, guilt, anxiety, or depression or I/we may be at risk for the development of delayed emotional distress or illness at some point in the future. Furthermore, undiagnosed or pre?existing mental disorders may be exacerbated or triggered by the emotional strains of IVF.
- I/We understand that there is an increased risk of multiple gestation with this procedure and that there are significant risks to the mother and to the fetuses. Multiple or "super twin" pregnancies can be physically and psychologically demanding and the source of considerable physical and emotional strain especially if the pregnancy is complicated, there are complications in the babies, and/or the pregnancy is lost. The medical staff has discussed the risks of a complicated and/or multiple pregnancy with me/us, and I/We understand them. I/We also understand that multi-fetal reduction is sometimes a consideration, and the medical staff has discussed this with me. Any number of psychological responses are normal, and I/We understand that I/We am encouraged to return for or seek additional psychological support elsewhere if the outcome of this pregnancy involves multiple gestation, complicated pregnancy, premature delivery and/or fetal loss.
- I/We understand that the IVF process may result in cryopreservation of "extra" embryos or embryos that are not transferred back at the time of the procedure. The process of cryopreservation has been discussed with me, and I/We feel comfortable with the decision I/we have made regarding disposition of embryos my partner and I/We choose not to use. I/We understand that our options regarding the embryos that are not used by me include: disposal, donation for research, and donation to another couple. I/We understand that feelings about the embryos now and in the future may be significant and that I/We should not make any decisions that feel uncomfortable or in conflict with our personal or religious values.
IVF/ICSI: In Vitro Fertilization/Intracytoplasmic Sperm Injection
- I/We understand that there is some evidence of increased risk of birth defects, specifically an elevated rate of chromosome anomalies, in fetuses conceived via ICSI (intracytoplasmic sperm injection) when a very low sperm count is noted. This increased risk may be due to genetic or inherited factors that caused the father's infertility necessitating the use of ICSI and, as a result, any offspring conceived as a result of ICSI may be at risk of inheriting the father's genetic disorder resulting in infertility or other unknown genetic disorders or problems in the offspring. I/We understand that either I or my partner may experience emotional distress, conflict, or regret should the outcome of the IVF/ICSI procedure be less then optimum and the child suffer inherited problems that were not predictable. If I have questions about ICSI or other medical treatments, I am aware that I should speak with my physician or the IVF nurse prior to beginning treatment.
Delayed psychological reactions to the IVF (in vitro fertilization) procedure could be triggered by recollections of the IVF (in vitro fertilization) process or by future life experiences including parenting any child(ren) born as a result of assisted reproductive technologies. Delayed reactions may include but are not limited to:
- Personal, social, religious, and legal attitudes about IVF (in vitro fertilization) may change in the future influencing my feelings and attitudes regarding assisted reproduction or feelings about the child(ren). For example, although I feel positively about IVF at this time, I/we may feel negatively about it in the future. Personal life events, such as other reproductive difficulties, parenting problems, or abnormalities in the offspring, may cause retrospective negative feelings about IVF, and I/we may experience anger, regret, anxiety, or depression or may develop delayed emotional distress or illness. Furthermore, undiagnosed or pre?existing mental disorders may be exacerbated or triggered by the emotional strains of the IVF process.
- I/We am aware that assisted reproductive technology is a relatively new medical field and is, to a large extent, ahead of social attitudes, law and legal precedent, and medical and social ethics. Knowledge of the long?term psychological and social consequences of IVF or participation in assisted reproductive technology is limited, but what is known has been discussed with me. I/We may experience unanticipated psychological distress, especially if attitudes and beliefs about IVF are different than current conventional wisdom or accepted practice.
- I/We understand that this evaluation does not address the legal, ethical, or religious ramifications of this procedure and that legal issues regarding IVF have not been fully addressed. Should I/We have any questions regarding these areas it is recommended that I obtain legal or religious counsel.
- I/We understand the risks, have been fully informed of them, and freely assume them.
- I/We acknowledge that the psychologist is not responsible for predicting or ensuring my current or future emotional responses or well being.
- I/We also appreciate that there is no certainty that I will achieve any benefit from this evaluation and that there is no guarantee that the outcome of the evaluation or the outcome of the IVF procedure will be a positive one.
I have read and reviewed the above and received a copy of this consent.