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Alternative Insemination Program
- Required Laboratory Studies

The following laboratory studies and a physical exam are required before acceptance into the AI Program.

PLEASE BRING PAPER COPIES OF LAB TEST RESULTS TO THE PRECONCEPTION COUNSELING APPOINTMENT.

Tests must be done within 1 year of AI enrollment visit:

  • Physical Examination  (visit notes, including blood pressure and BMI)
  • Pap Smear
  • Chlamydia (cervical culture or urine test)
  • GC (cervical culture or urine test)

Tests must be done within 6 months of AI enrollment visit:

  • HIV antibody
  • Blood Group/Rh factor (or proof of blood group/Rh factor)
  • HBsAG (Hepatitis B)
  • Rubella Titer (or proof of vaccination)
  • Syphilis (RPR)
  • Hemoglobin A1c, if diabetic

The following tests may be required:

  • If  35 or older:  FSH and estradiol on day 3 of menstrual cycle
  • Prolactin
  • TSH
  • Progesterone 7 days after presumed ovulation (may be cycle day 21)
  • HCV (Hepatitis C)
  • Varicella (Chicken Pox)
  • Sickle Cell (if African American descent)
  • Tay Sachs (if French-Canadian descent)
  • Jewish genetic panel

 

FENWAY COMMUNITY HEALTH  ALTERNATIVE INSEMINATION PROGRAM

Dear Provider:

Due to the high cost of alternative insemination and the fact that many of our clients are 35 years of age or older, we recommend that the following tests be considered between the first and sixth insemination attempts. Please discuss these tests with your client to determine if you and she are interested in doing them at this time.

                FSH                        Draw on day 3 of menstrual cycle.

                Estradiol                Draw on day 3 of menstrual cycle.

                TSH

                Prolactin

                Progesterone        Draw 7 days after ovulation (may be cycle day 21).

 

Do you feel that this client possesses risk factors that warrant either of the following tests?

                Endometrial Biopsy:

                Hysterosalpingogram:

 

I have explained to this client that I am not affiliated with Fenway Community Health nor do I take responsibility for the Alternative Insemination Program at the Fenway Community Health.

I have, however, reviewed __________’s Medical History and have completed the required Fenway Community Health Physical Examination and Laboratory Tests, as well as other tests I recommended. Based on the normal and satisfactory results of these procedures, I, the undersigned do hereby certify to the best of my medical judgment that this client is in adequate physical condition to become pregnant through alternative insemination.

 

Date: __________ Provider’s Signature: __________

After completion of this form, please return the Medical History and Physical Examination and hard copies of Laboratory Studies to:

Alternative Insemination Program

Fenway Health
1340 Boylston Street
Boston, MA  02215
617-927-6180  voice mail
617-247-3460  FAX

 

The following tests may be required:

● If 35 or older: FSH and estradiol on day 3 of menstrual cycle
● Prolactin
● TSH
● Progesterone 7 days after presumed ovulation (may be cycle day 21)
● HCV (Hepatitis C) 
● Varicella (Chicken Pox)
● Sickle Cell (if African-American descent)
● Tay Sachs (if French-Canadian descent) 
● Jewish genetic panel


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