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OUTCOME OF INSEMINATION REPORT

The California Cryobank (CCB) encourages all clients to complete the following Outcome of Insemination Report. The report should only be filled out when you have finished ordering specimens from CCB, so that you may report on the results of all vials at one time. This report provides information necessary to monitor the effectiveness of our specimens. When you complete this report, please be sure to press the submit button at the bottom of the page. All information is strictly confidential. If you have any questions about the Outcome of Insemination Report, please call 800-977-3761, ext. 7100 or ext. 1240.

* Required Fields
Account Number *
Donor Number *
Vial Number(s) (ie. 3442, 05.11.02 CCB-02) or if vial number is unknown please give the date the vials were shipped (mm/dd/yyyy) *
Date of Insemination (mm/dd/yyyy) *
How many cycles was the recipient inseminated or how many Assisted Reproductive Procedures were performed?
How many inseminations per cycle?
How many vials were used for each cycle or Assisted Reproductive Procedure?
Method of insemination:
IVI ICI IUI IVF GIFT ZIFT Other
Were fertility drugs used? Yes No
      If yes, which drug(s)?
If recipient had an IVF procedure, are embryos being stored? Yes No
      If yes, how many are in storage?
Recipient Year of Birth (yyyy)
Procedure Result:
Recipient is not pregnant
Recipient is currently pregnant

Expected delivery date (mm/dd/yyyy):

Recipient had a pregnancy loss
Nature of loss: Spontaneous abortion
Therapeutic abortion
Other
Was the fetus normal? Yes No
If you would like to speak to a genetic counselor, please call ext. 1040.
Recipient gave birth
Date of birth (mm/dd/yyyy):
Number of boy(s)
Number of girl(s)
Was the health status normal? Yes No
If you would like to speak to a genetic counselor, please call ext. 1040.
Email Address
Phone Number
This information is strictly confidential and will only be used in the case that we have a question regarding your insemination report.
Questions/ Comments:
California Cryobank thanks you for filling out this report.
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