If pregnancy is not achieved after 4 cycles of ART procedures as defined above, the patient will be able to receive one free donor sperm vial, of equal or lesser value.Proof of age will be verified by the physician completing the Fairfax Pregnancy Pledge® Physician Verification form.Patient who is receiving the ART procedure must be 38 or younger by the date of the first ART procedure This form is available by contacting Client Services at 80, who will fax it directly to the physician’s office.Ĥ. Fairfax Pregnancy Pledge® Physician Verification form must be verified and signed by a physician or other relevant medical professional in order for the patient to be eligible for 1 free donor sperm vial. If 2 inseminations occur within one cycle, this counts as 1 cycleģ.All ART procedures must occur within 12 months of the first procedure date, and after April 5, 2010.Home insemination will not be counted towards the 4 ART procedures.Patient has gone through at least 4 cycles of assisted reproductive technology (ART) procedures, which include artificial insemination or in vitro fertilization (IVF) performed by a licensed physician. The sperm must be purchased after April 5, 2010.Ģ. The orders may all be at different times. Patient purchased at least 4 vials of donor semen from Fairfax Cryobank. Pregnancy Pledge® Free Sperm Vial Guidelines:ġ.
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