Pregnancy Report

We maintain complete records of pregnancies. This helps us maintain a donor's family limit, track health and medical information for donors, recipients, and children, and provide ongoing services to families after children are born. For more information regarding the importance of reporting all pregnancies and outcomes, please click Pregnancy Outcome Reporting.

This report concerns your most recent pregnancy with TSBC samples. If you are unsure about a question or prefer not to answer, just leave it blank or enter 'unsure' / 'withheld.' We guarantee complete confidentiality. No identifying information will be released. If you prefer to mail or fax the form, click here for a pdf version or simply fill out the form below, print it, and fax or mail it in. Thank you for your time.


* = Required Field

Recipient's name	*
Partner's name (if applicable)
Have you moved?
New address
New home phone number
New cell phone number
Donor #	*
Recipient's age at insemination

---

Insemination Dates of Conception Cycle Only
Date of Insemination 1 (mm/dd/yyyy)
Date of Insemination 2 (mm/dd/yyyy)
Date of Insemination 3 (mm/dd/yyyy)

---

If you used IVF, is the insemination date the date of Retrieval     Transfer   Methods of Insemination: (check all that apply) Vaginal Pool (ICI) Intra-uterine (IUI) IVF ICSI Surrogacy
Did you use egg donation?	Yes   No   N/A
Number of vials used (for conception cycle only)
If yes, did you use your partner's eggs?	Yes   No   N/A
Insemination Setting	Home Clinic/MD office
Cycle #:
Due Date:
Number of vials used
Number of vials *NOT* used (i.e., still at doctor's)
How were the vials transported?	Shipped Picked-up
Transported in:	Liquid Nitrogen Tank Dry Ice

---

Means to determine ovulation:	(check all that apply)
	Ovulation predictor kit Ultrasound Cervical exam Fertility monitor Blood test/s Basal body temp Mucus Controlled cycle (i.e. IVF) Mittelschmerz pain Other

---

Fertility drugs used for this conception?	Yes   No   N/A
If yes, which one(s)	Clomid HCG Repronex GonalF Menopur Other:
How many pregnancies have you had with TSBC?
Do you have other TSBC children?	Yes   No   N/A
If yes, how many?
Did your partner ever conceive with TSBC sperm?	Yes   No   N/A

What is your parenting arrangement
Single
Couple
Other

We track sexual orientation for research purposes and in order to apply for specific grant funding. How do you identify?
Lesbian
Heterosexual
Bisexual
Other

Interested in purchasing sibling inventory? Yes   No   N/A
- This question helps us determine how many vials to save. If vials are available, you can guarantee availability by purchasing them.



Questions/Comments:


Please help us fight spam:

Type the two words, then click "submit" to process your report. You will receive a confirmation of your submitted report.

Privacy Policy
last updated: 04.19.2009 form submission edits: 10.14.2009