All of the following requirements must have been completed within the past year       

• Initial Consultation with your provider
• History and Physical Examination, PAPs smear (less frequent ok if SRM MD approved), mammogram for patients >40.
• Psychosocial Education Appointment as a couple.
• Tubal Evaluation:  Hysterosalpingogram (HSG)
• An HSG is an x-ray test designed to evaluate 1) the Fallopian tubes (are they open or not?) and 2) the shape of the uterine cavity.   A small amount of sterile, iodine-containing fluid is injected through a small catheter that has been placed into the cervix.  Continuous x-rays (fluoroscopy) will be taken as the contrast fills the uterus and flows through the Fallopian tubes. If you are allergic to iodine, please let your physician know.   In most cases, this test takes only a few minutes to perform and is associated with mild discomfort and cramping.  In cases of tubal occlusion, you may experience more cramping. 
• Screening Blood Tests:
• Blood Type & RH
• Hepatitis C Antibody
• Hepatitis B Surface Antigen & Hepatitis B Core Antibody
• HIV 1 & 2
• RPR (Syphilis)
• Chlamydia and Gonorrhea cultures (Urine or Swab)
• Herpes II
• Rubella Immunity Titer
• Varicella Immunity Titer (Chicken Pox, if negative clinical history)
• CMV IgG & IgM
• Cystic Fibrosis Screening (Recommended)

Male or Female Partner Screening Requirements

• Screening Blood Tests

• Hepatitis C Antibody
• Hepatitis B Surface Antigen
• HIV 1 & 2
• RPR (Syphilis)
• Blood Type & RH (suggested)

Revised June 12, 2008