Patient Name:

Age:

Date:

Procedure: Epididymal/testicular sperm aspiration and/or testes biopsy

Indications:

Patient is a male patient with infertility (azospermia or severe oligoasthenospermia). The patient requests a diagnostic explanation for his condition or is part of an artificial reproductive techniques program and this procedure will serve to harvest viable sperm for intracytoplasmic sperm injection (ICSI). The remainder of the viable sperm will be frozen and available for future cycles

Alternatives:

Alternatives include donor sperm or adoption.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: local hematoma formation, chronic epididymal or testicular pain or infection and failure to find viable sperm.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________