Linda A. Baker, MD

• Professor, Department of Urology, Pediatric Urology, and
• Director of Pediatric Urology Research,
• The University of Texas Southwestern Medical School at
• Dallas, Dallas, Texas

Persons incarcerated in a city medications for migraines buy clozaril cheap, county symptoms mononucleosis discount 50mg clozaril, State medications available in mexico buy discount clozaril 100mg line, or federal correctional facility q medicine 0552 purchase clozaril overnight. Contractor recognizes value-based payment models as those that reward Providers for outcomes crohns medications 6mp buy clozaril 25 mg mastercard, including improving the quality of services provided symptoms qt prolongation buy cheap clozaril 25mg online, promoting provision of appropriate services, and reducing the total cost of services provided to Medicaid beneficiaries. Supplemental payments to build practice-based infrastructure and Enrollee management capabilities. Payment for new services that promote more coordinated and appropriate care, such as care management and community health work services, that are traditionally not reimbursable 3. Contractor must contract with providers in their network to provide care management and care coordination services to their members with contracts effective January 1, 2020. Contractor must coordinate health plan care management activities and care managers with care management and coordination activities and staff embedded in participating practices, and 5. Contractor recognizes the importance of integrating both physical health and behavioral health services in order to effectively address Enrollee needs and improve health status. Contractor must not discriminate against individuals eligible to enroll on the basis of: a. Contractor must accept Enrollees for enrollment in the order in which they apply without restriction. Enrollees disenrolled from the Contractor due to loss of Medicaid eligibility or other action will be retroactively reenrolled to the same Contractor automatically, provided eligibility is regained within two months. Enrollment Lock-In and Open Enrollment for Beneficiaries in Counties Not Covered by Exceptions Except as stated in this subsection, enrollment with the Contractor will be for a period of 12 months with the following conditions: 1. Enrollees will be provided with an opportunity to select any Contractor approved for their county of residence during the annual open enrollment period. Enrollees will be notified that inaction during open enrollment will retain their current Contractor enrollment. Enrollees who choose to remain with the same Contractor will be deemed to have had their opportunity for disenrollment without cause and declined that opportunity until the next open enrollment period. New Enrollees or Enrollees who change from one Contractor to another will have 90 Days from the enrollment begin date with the Contractor or during the 90 days following notification of enrollment, whichever is later, to change Contractors without cause. Contractor must provide Covered Services and coordination for services to Enrollees until their date of disenrollment. When an individual is determined eligible he or she is eligible for that entire month. With the exception of newborns, when an individual is determined to be Medicaid eligible, enrollment with a Contractor will occur on the first day of the next available month following the eligibility determination and enrollment process. With the exception of newborns, the Contractor will not be responsible for paying for health care services during a period of retroactive eligibility prior to the date of enrollment with the Contractor. If the Beneficiary is in any inpatient hospital setting on the date of enrollment (first day of the month) Contractor will not be responsible for the inpatient stay or any charges incurred prior to the date of discharge. If an Enrollee is disenrolled from a Contractor and is in any inpatient hospital setting on the date of disenrollment (last day of the month) the Contractor must be responsible for all charges incurred through the date of discharge. If the child was not admitted to a facility when the eligible condition was identified, the first of the month that eligible condition was identified by a pediatric subspecialist and services for the condition were provided. Disenrollment provisions apply to all Enrollees equally, regardless of whether enrollment was mandatory or voluntary. Violent/threatening situations involve physical acts of violence; physical or verbal threats of violence made against Contracted Providers, staff, or the public at Contractor locations or stalking situations. Contractor must make contact with law enforcement, especially in cases of imminent danger, when appropriate, and refer the Enrollee to behavioral health Providers when appropriate, before seeking disenrollment of Enrollees who exhibit violent or threatening behavior. If the Beneficiary exercises their right of Appeal, the effective disenrollment date must be no later than 30 Days following resolution of the Appeal. Contractor is prohibited from requesting disenrollment of an Enrollee for reasons other than those permitted in this Contract. Contractor may require Enrollees to use Network Providers and provide transportation and/or authorize Out-of-Network providers to provide Medically Necessary services. Contractor will receive a Capitation Payment for these Enrollees at the approved statewide average rate until disenrollment. When requesting disenrollment, Contractor must submit verifiable information an Enrollee has moved out of the service area. Contractor may initiate a disenrollment request if the Enrollee is admitted to a nursing facility for custodial care or remains in a nursing facility for rehabilitative care longer than 45 Days. The facility must be enrolled in the Medicaid program before disenrollment can take place. Contractor must request disenrollment within 15 Days of identifying the administrative circumstance. Lack of access to Providers or necessary specialty services covered under the Contract. Enrollee may request disenrollment from the Contractor if the open enrollment period was not available due to a temporary loss of Medicaid eligibility. The effective date of an approved disenrollment must be no later than the first day of the second month following the month in which the Enrollee requests disenrollment. If the State fails to make a determination within this timeframe, the disenrollment is considered approved for the effective date that would have been established had the State complied with the required timeframe. Contractor must make Covered Services available 24 hours a day, seven days a week, when Medically Necessary. Contractor must ensure that Network Providers provide physical access, reasonable accommodations, and accessible equipment for Medicaid Enrollees with physical or mental disabilities. Contractor must establish mechanisms to ensure Network Providers compliance with standards in this Contract, including monitoring Network Providers regularly to determine compliance and taking corrective action if there is a failure to comply by a Network Provider. Contractor must consider anticipated enrollment and expected utilization of services with respect to the specific Medicaid populations. Contractor must consider the geographic location of Providers and Enrollees, including distance, travel time and available means of transportation ordinarily used by the Medicaid population and whether the Provider Network locations provide access for Enrollees with physical or developmental disabilities. Contractor must provide for a second opinion from a qualified health care professional within the network or arrange for the Enrollee to obtain one Out-ofNetwork at no cost to the Enrollee. Contractor must attest to and demonstrate compliance with contractual network adequacy and timeliness to care requirements on at least an annual basis. Contractor must develop, submit and comply with a Network Access Plan which describes its network development and network management activities and results. The report must include any findings of Provider non-compliance and any corrective action plan and/or measures taken by the Contractor to bring the Provider into compliance. Maintains a network of Providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of Enrollees in the service area. Providers that are not accepting new patients, including Providers with some conditions on accepting new patients must be excluded from geo-access time and distance tables. Additional time and distance tables of all providers, including those not accepting new patients, may be submitted. Contractor must submit documentation attesting to network adequacy, including modifications to its Network Access Plan, if: a. Contractor must make a good faith effort to give written notice of termination of a Network Provider within 15 Days after receipt or issuance of the termination notice to each Enrollee who received primary care from, or was seen on a regular basis by, the terminated Provider. Contractor must ensure Enrollees have access to emergency and Urgent Care Services 24 hours per day, 7 days per week. Contractor must require that physician office visits be available during regular and scheduled office hours. Contractor must ensure that Enrollees have access to evening and weekend hours of operation in addition to scheduled daytime hours. Contractor must make available direct contact with a qualified clinical staff person through a toll-free telephone number at all times, 24 hours per day, 7 days per week. The amount of time between scheduling an appointment and the date of the office visit including routine appointments, urgent appointments and emergent appointments. Contractor must provide adequate and timely access to , and authorize and reimburse Out-of-Network providers and cover Medically Necessary services for Enrollees if such services could not reasonably be obtained by a Network Provider on a timely basis inside or outside the State of Michigan. If Contractor cannot reasonably provide access to non-emergent Covered Services by a Network Provider within access requirements of this Contract, Contractor must include in its service authorization decision, the provision of Covered Services Out-of-Network. Contractor must comply with all related Medicaid Policies regarding authorization and reimbursement for Out-of-Network providers. If Michigan Medicaid has not established a specific rate for the Covered Service, the Contractor must follow Medicaid Policy to determine the correct payment amount. Management by a physician specialist will be determined on a case-by-case basis in consultation with the Enrollee. Provides expanded appointments when children have complex needs and require more time. Has experience coordinating care for children who see multiple professionals (pediatric subspecialists, physical therapists, behavioral health professionals, etc. Has a designated professional responsible for care coordination for children who see multiple professionals. Provides services appropriate for youth transitioning into adulthood, including but not limited to; the use of a transition assessment tool and adoption of a transition policy that is publicly posted and specifies: i. Contractor must demonstrate that its network includes sufficient family planning Providers to ensure timely access to Covered Services. Contractor must ensure that Enrollees have full freedom of choice of family planning Providers, both in-network and Out-of-Network. Contractor must allow Enrollees to seek family planning services, drugs, supplies and devices without prior authorization. Contractor must maintain accessibility and confidentiality for family planning services through promptness in scheduling appointments, particularly for minors. Contractor must make certain Medicaid funding is not used for services for the treatment of infertility. Contractor must allow women who are pregnant at the time of enrollment to select or remain with the Medicaid maternity care provider of her choice. Contractor must allow pregnant women to receive all Medically Necessary obstetrical and prenatal care without prior authorization regardless of whether the provider is a contracted in Network Provider. Contractor must ensure an individual maternity care Provider is designated for each enrolled pregnant woman for the duration of her pregnancy and post-partum care. Contractor recognizes the need for adequate network access for mild to moderate behavioral health services for the young Medicaid population. Indian Health Service/Tribally-Operated Facility/Program/Urban Indian Clinic (I/T/U) 1. Demonstrate that there are sufficient I/T/Us participating in the Provider Network to ensure timely access to services available under the Contract from such Providers for Native American Enrollees who are eligible to receive services. Pay I/T/Us, whether in the Provider Network or not, for Covered Services provided to Native American Enrollees who are eligible to receive services from such Providers as follows: i. In the absence of a negotiated rate, at a rate not less than the level and amount of payment that the Contractor would pay for the services to a participating provider which is not an I/T/U; and iii. Permit Native American Enrollees to obtain Covered Services from Out-ofNetwork provider from whom the Enrollee is otherwise eligible to receive such services. Permit an Out-of-Network I/T/U to refer a Native American Enrollee to a Network Provider. If timely access to Covered Services cannot be ensured due to few or no I/T/Us, Contractor will be considered to have met the requirement in paragraph (1)(a) of this section if Indian Enrollees are permitted by Contractor to access out-of-State I/T/Us 3. If the I/T/U is not contracted with the Contractor, Native Americans must still be allowed to use the provider without authorization. Contractor must ensure services appropriate for youth transition into adulthood, including the adoption of a comprehensive transition policy and readiness assessment of need for a care manager and family-centered plan.

Most mothers take the parental leave Apply for ofcial identifcation for your baby Healthy Kids program at 1-866-866-0800 symptoms adhd order clozaril on line. And talk to may pay for medical and dental costs your employer about any additional benefts not covered by other insurance medications with sulfur purchase clozaril 100 mg. If not medicine 319 pill order 100 mg clozaril mastercard, you may be also choose to give her one or more middle consent box on the back of the form you able to get help through the Interim Federal names medications bad for kidneys order clozaril without prescription. After Jacob came into our lives fi Never heat a baby bottle in the microwave my partner and I would pass by each other or on the stove treatment non hodgkins lymphoma 25mg clozaril sale. Neither is or blocking the tubes that carry eggs a year douching or rinsing the vagina after sex medicine zantac purchase clozaril paypal. Follow the same routine for unexplained death of a healthy baby while bath, rocking, singing and quiet time naps and at night. If your baby falls asleep in the car, check Bed fi Crib, cradle or bassinet that has fi Drop-side crib (banned for sale since 2016) been approved by Health Canada on her regularly. Once you get to your fi Co-sleeper crib that attaches to your bed (ask your health care provider if destination, move her to a safe sleep space. Once she can roll easily from back to air mattress, beanbag, waterbed) front and back again (usually at around 5 to 6 fi Torn mattress months), you no longer have to turn her over. Never share a bed if: Sleeping in the same room as your baby, but fi the adults in the bed both know that the baby not in the same bed. She frst 6 months is in her own safe sleep space in can be smothered by the blanket or get stuck on Is it recommendedfi But some families prefer to bedshare her stomach and be unable to move into a safer Bedsharing can be risky, especially for some babies. Even cofi Your baby is far away from pillows, blankets over her face or head sleeper cribs that attach to the side of your bed and duvets. As she grows, it helps her develop good emotional and mental health, build strong relationships, and have the confdence to explore the world around her. After the frst month, once Chat with your baby as you change Days 4-6: every few days or even just once a week. When the pail is full, empty it into the fi cost more than cloth him a toy to keep him busy. Wash in hot water flled to the highest a warm, wet washcloth or unscented water level. If you use deodorizing tablets, keep fi can be bought or homemade your diaper pail out of reach of children. Once Start with the face, using only water, and Safer bathing her frst teeth appear, use a soft baby toothbrush clean the diaper area last. Use a mild, and a grain of rice-sized dab of fuoride fi Always have at least one hand on your baby unscented soap on visibly dirty parts, toothpaste in the morning and at bedtime. Support him with a rolled up towel under tummy time, and only use tummy time his chest and a hand under his chin. Early treatment re-checked if you have future concerns about vitamin K and prevent serious bleeding. If you can prevent developmental delays, growth his hearing, speech or language development. Some may cause 4 to 6 years, 11 years (Grade 6), and 14 years child from getting serious diseases including: soreness or slight fever, but these side efects (Grade 9). Talk with your doctor or public health are minor and usually last only 1 or 2 days. Children with a family history Health Canada warns that (which can be dangerous), or forehead strips, gentian violet (also known as crystal violet) pacifer thermometers or ear thermometers of crossed eyes are more likely to be afected. Always check with your health care provider before giving your baby any medication. In most In the frst few weeks, your baby may have tiny Coughing and sneezing cases, it will go away with extra feeding. Test a small well, and using a thin layer of zinc-based cream amount on your baby frst, then use as Laxatives, suppositories and enemas should little as possible. And mouth or dipping it in honey or syrup can and talking with your health care provider always secure the 5-point harness. Ensure the harness straps are at his your child facing the back of the car for as long shoulders or slightly below. Lower the carrying handle behind an seat on a table, counter or anywhere else infant seat. Together, they set him healthy, and ensuring they sleep well and get By communicating with your baby, you can help up for success in everything from learning to enough to eat. But every child develops at their own pace, a instead of hitting a ball back and forth across healthy brain supports development in all areas. The Canadian Paediatric Society recommends no screen time for children under the age of 2.

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Nabothian cysts Secretions back up in the papillary dermis resulting in the formation of a large cyst. Endocervical Polyp Ectocervix Ectocervix Mass protruding through cervical os Occur in 2-5% of adult women. Cancer Most patients with high stage cervical Rectum carcinoma die due to local extension into the urinary tract. Obstruction of the ureters can cause post-renal azotemia and predispose patients to pyelonephritis/ urosepsis. Bladder Tumor Tumor has invaded Vagina posteriorly into the 53 rectum and anteriorly into the bladder. Cervical Cancer-Treatment Surgery for stage 1 Chemoradiation for stage 2-4 57 Cervical Dysplasia Four Key Concepts! Describe the role of screening prevention of cervical cancer 73 Take home message: Please make sure female patients age 21 and older get cervical cancer screening! The following pages contain guidelines for the control and reporting of diseases in the school-age population and among staff members of schools in the state of Washington. Otherwise, this guide is not intended to be inclusive of adult/employee illness or disease. Note that schools are not responsible for notifiable conditions reporting if a health care provider or laboratory makes the initial diagnosis of the case. A school should report an outbreak that is associated with the school whether or not it involves a notifiable condition and should report any suspected cases of notifiable conditions that are not yet diagnosed. Consult with a licensed health care provider or your local health jurisdiction for information regarding infectious diseases, when necessary. School staff should also report suspected or confirmed outbreaks associated with the school. The local health officer shall take whatever action he/she deems necessary to control or eliminate the spread of the disease. This guide provides information to school personnel regarding appropriate actions that can be taken to identify infectious diseases, to assure appropriate health care for students and staff, and to control the spread of disease. At-Risk Populations In any school population, there are certain individuals who may have a higher risk of complications if exposed to specific diseases. The licensed health care provider will assess the risk and make appropriate recommendations for treatment of his/her patient. Hand sanitizers are never appropriate when there is significant contamination such as occurs during a visit to a petting zoo or farm, after handling an animal, after changing a diaper, after playing outside, before preparing food or eating, after touching an infected wound, or after using the bathroom. Hand sanitizers have not been shown to be effective against norovirus or Clostridium difficile spores or for soiled hands. Home/Hospital Home/hospital instruction is provided to students who are temporarily unable to attend school for an estimated period of 4 weeks or more because of physical disability or illness. Behavior Irritability may be associated with illnesses, often because of the accompanying fatigue, fever, and discomfort. Fever Parent/guardian and school staff may experience concern about fever, and yet fever does not automatically require intervention. Several scientific studies have shown that fever rarely causes harmful effects in itself. Recurrent low-grade fever may occur as the result of physiological changes in the body and may not cause any discomfort to the student. Symptomatic treatment of any illness in the school setting should be undertaken only if the parent/guardian has complied with school policy on the administration of oral medications for symptomatic treatment of illness or injury. Cramping accompanied by fever and bloody diarrhea are always serious medical concerns and should be immediately referred to a health care provider for evaluation. The local health jurisdiction may require that children or employees with certain infections not return to school until testing negative for the infection. If a student vomits or has diarrhea at school, contact the school nurse for guidance. If the school nurse is not available contact the parent and have the child go home for further observation. Nasal Discharge and Obstruction Clear nasal discharge may signal an infection such as a cold or it may indicate an allergic reaction, especially if accompanied by watery eyes. Sore Throat A sore throat can be a minor problem, but it can also indicate more significant infections such as streptococcal pharyngitis, infectious mononucleosis, or other serious generalized illnesses. Persistent coughs, especially with other symptoms such as episodes of coughing followed by gagging, or a whooping sound, vomiting, fever, loss of appetite, or weight loss, need medical evaluation. When a notifiable condition is suspected, the local health jurisdiction should be contacted. Similar fungal infections occurring on the body or head are called ringworm (see Ringworm). Students with an active infection should not use wet or damp areas withere the infection can be transmitted. Bed bugs occur primarily in buildings with shared housing, such as hotels, motels, and apartment buildings. It is rare for a school to have bed bug infestations because bed bugs feed at night. If a bed bug is tentatively identified, a person experienced with bed bug identification should thoroughly inspect the area. Personal items such as coats and backpacks should be stored in plastic containers or bags (both at home and at school) while the problem is being resolved. Resources Bed Bugs: What Schools Should Know (May 2010) Michigan Bed Bug Working Group. Most schoolroom bites are from laboratory or small pet animals such as white mice, gerbils, guinea pigs, and hamsters. Bites from these animals are generally minor injuries and since the animals are not wild, there is very little risk of rabies. Although tetanus may be the first infection that comes to mind in connection with a bite, other infections, severe bruising, or skin cuts may occur. Rare infections, such as lymphocytic choriomeningitis virus have been spread from mice or hamsters. Animal feces, which can contaminate the entire animal, can transmit infections such as salmonellosis and hand washing with soap and water is important after handling animals. Elsewhere in the United States, rabies has been associated with bats, raccoons, foxes, skunks, coyotes, and occasionally other animals bitten by a rabid animal. Prompt medical treatment following an animal bite can reliably prevent rabies from developing. Any suspected human exposure to rabies from an animal should be evaluated by your local health jurisdiction or a designated authority. Wounds of the lips and the tissue surrounding the fingernails account for most self-inflicted bites that come to the attention of medical personnel. Human bites may also be caused by, or have reason to be investigated for, child abuse. Remember that although tetanus may be the first infection that comes to mind in connection with a bite, other infections, severe bruising, or skin cuts may occur. Incubation Period Development of infection from a bite depends on the depth of the wound, the extent of tissue damage, and the type of infecting bacteria. Provide basic first aid immediately, washing the wound thoroughly with soap and water. Report to building administrator and document incident per district policy and procedure. They will have fewer spots which may not appear typical and may not have vesicles (blisters), and they are less likely to have a fever, and usually recover faster. Use of antiviral medication such as acyclovir, may decrease the number of lesions and duration of outbreak of lesions but is most beneficial if started within 24 hours of rash development. Pregnant women who have been exposed to somebody with chickenpox should contact their doctor immediately. Dispose of bandages that have been in contact with the vesicles (blisters) in appropriate bagged receptacle. Health care providers who do not wash their hands between patients can transfer the infection from one patient to another. Soap and water is the best choice for hand hygiene when someone is infected with C. Carry out proper handwashing techniques, dispose of feces-contaminated materials properly, and clean and disinfect areas contaminated by feces appropriately because an infected individual may show no symptoms. Remove and dispose of gloves properly following diaper change and wash hands with soap and water immediately. Infectious Period the common cold is infectious a few days before the onset of symptoms and while clear, running secretions are present. Infants, children, and teenagers should not use aspirin unless prescribed by a health care provider because of its association with Reye Syndrome. Eyelids stuck together after sleeping are most common with bacterial conjunctivitis. It is contagious while symptoms are present, or until a course of treatment (such as an antibiotic) is started. Frequent handwashing is the best method to control and prevent the spread of conjunctivitis. Advise students to throw away and replace cosmetics that were used during the infection. Report to your local health jurisdiction clusters of cases, regardless of the suspected cause of conjunctivitis. Educate students not to share personal items that touch the eyes, such as towels and cosmetics. Remind students to wear, handle, store, and clean their contact lenses as instructed by their licensed eye care provider. Instruct staff who care for infants in proper methods of diaper changing and disposal of soiled materials. Type and severity of symptoms vary by the causative organism and the resistance of the person infected. Determining the specific cause of infectious diarrhea is difficult in a school setting. A student with severe or persistent diarrhea, especially if accompanied by fever and cramps, should be referred for medical care. Immediately report to your local health jurisdiction groups or clusters of suspected foodborne or waterborne illness associated with the school. Report to your local health jurisdiction parental reports of children infected with notifiable conditions such as Salmonella, Shigella, Shiga toxin-producing E.

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Cancer risks assoresults and obstetrical outcomes in patients 45 years ciated with the diagnosis of infertility medications while breastfeeding buy clozaril 50 mg. Nationwide data on falling incidence of ovarian Assisted reproductive technology and the incidence granulosa cell tumours concomitant with increasing of ovarian cancer: a meta-analysis medicine for stomach pain purchase clozaril line. Fragouli E symptoms 7 days after embryo transfer clozaril 100mg low price, Escalona A medications prescribed for pain are termed purchase clozaril 50 mg overnight delivery, Gutierrez-Mateo C symptoms 3 days after conception discount clozaril master card, Tormasi clomiphene citrate to induce ovulation treatment syphilis generic clozaril 25mg visa. Ameratunga D, Weston G, Osianlis T, Catt J, ploidy screening is significantly more consistent Vollenhoven B. Improvements attempts at human in vitro fertilization induced by achieved in an oocyte donation program over a follicular puncture rather than hormonal stimulation. Shortly thereafter, a group from also offer egg donation, and, across all age Monash University (Australia) reported a live groups, nearly 10,000 donor-conceived freshbirth from a single, donated, unfertilized ova embryo transfers were reported for 2010 [1 ]. The patient might have been approached by her physicians and asked if she would donate the supranumerary eggs to another History cycling patient whose response to stimulation was poor. On the fifth day observation of the author, at the time a registered following the insemination, Dr. This source of donated eggs was relatively short-lived, since, with improved methods of cryopreservation, fertility M. Whether or not the use of in the late 1980s, fertility centers began recruitdonor gametes should be disclosed to a donoring donors from the community at large, rather conceived child, how that is best done, when the than from among their population of fertility topic should be approached, and other disclosure patients. At this time, the donation was contemissues are pertinent (and controversial) whether plated as simply that, with reimbursement only the donation is of egg or sperm. Additionally, for actual expenses and recipient payment for the since a majority of the states have codified varimedical procedures. However, donor participaous aspects of sperm donation (including parention was sparse, and beginning around 1990, a tal rights for the intended father, donor rights and few fertility centers began advertising for paid procedural requirements, among other things), a donor candidates, offering compensation for model for asserting equal rights protection for time, inconvenience, and other intangibles. In 1991, models for egg donation laws, it is important to one of the first commercial egg donor recruiting/ note that the state laws regarding donor sperm are matching groups was started in California [4]. Some of these laws only offer protection Since the 1990s, with the notable exception of if the intended father is married to the mother; egg freezing, the basic science involved in egg some, but not all, specifically terminate the rights donation has not dramatically changed, although of the donor; a number of them require profestreatment protocols continue to be refined and sional medical participation or supervision; and improved. The complex practical and legal several require consent of the intended father to aspects of egg donation have shifted dramatically, the procedure, while others allow for implied though, as the need for donors continues to grow. While the framework of sperm donation has been helpful in the development and analysis of the Legal Landscape egg donation issues, there are obvious and significant differences between the two. The time An egg donor is a woman who contributes her commitment required and the complexity of genetic material, usually for reproductive purmedical participation for an egg donor have no poses, to another. While unlikely, if the parent of any resultant child and waives any rights donor develops a medical complication, it can she may have to the eggs upon the donation. Accordingly, utilization as a solution for male infertility, in response to the special concerns raised by egg informed the early development of approaches to donation, professionals in this area have egg donation. For instance, the concept of developed medical and psychological screening anonymity in egg donation follows the usual parguidelines for all participants, considered and adigm in sperm donation. Sperm donation paved formally commented on myriad ethical issues, 2 Oocyte Donation: Legal Aspects 33 and suggested legal protections for participants donor eggs or improper informed consent is also and medical providers [5, 6 ]. This process adoption), a woman with a genetic but not gestatallows a frank discussion of the legal risks and an ing connection to the child, a woman who has explanation of rights and responsibilities by an given birth to the child, or a woman who has the expert who acts as an advocate for his or her client. Furthermore, in other issues may not be encompassed by existing situations where donor-conceived babies are gesprotections. For example, in states where there is tated by the (married) intended mother, the overno law, the process for determination of the whelming trend is to recognize the gestating parental status of the intended mother and woman as the legal parent of the child. Swain having noted that the parents had entered into a ruled that an oocyte donor had parental rights to written egg donation agreement that documented triplets born to the carrier. The carrier had refused their intentions to both be parents, went on to to release the triplets to their genetic father, and declare that the father had no superior claim to the donor asserted her claim of parental rights the twin girls. A California case exemplifies challenges since donor had waived her rights, the only parfaced by fertility centers working with these ent is the father), custody of the triplets was patients. There was no written mix-ups of gametes/embryos created with donor parentage agreement between the two women, gametes. Screening of egg donors for communiand the genetic mother did not subsequently adopt cable diseases and heritable disorders requires the twins who were born from the arrangement. In a 2003 case, an egg who gave her oocytes to her lesbian partner, who, donor tested positive as a carrier of the cystic with donated sperm, conceived and gave birth to a fibrosis gene mutation, but the test result was not child, was not a parent. The medical forms used by the medical facility, and noted that practice did not test the intended father for carrier no further action was taken by the plaintiff to status. The lower level appeals claim for wrongful life, it permitted the parents to court also found in favor of the birthing mother. Some of the embryos were recognized that the two women intended to raise inadvertently switched, and Susan received one any resultant child together. The parties learned this from father who was also the genetic father and was the clinic 10 months after a child was born to unmarried, his unmarried partner and intended both Susan and to the wife, Denise. Denise and mother, a married gestational carrier and her husRobert filed a parentage action. However, since Denise the early 1990s, a California couple received an had no genetic or gestational connection to the embryo created with donor gametes and conchild, the court dismissed her from the case, nottracted with a gestational carrier to carry the preging that her situation was distinguishable from nancy. During the pregnancy, the intended parents cases where an intended mother contracts with an separated. The gesings, the husband contested any claim that the tating mother retained custody of the child and child was a child of the marriage, a determination was declared to be the mother [13 ]. Carolyn decided to carry the Always a controversial area, egg donation has child and, upon delivery, to place the baby with been the subject of much scrutiny and negative the genetic parents. The parties resolved the parpublicity regarding excessive payments to egg entage issue among themselves, but not without donors, reputed to be, in some cases, up to tremendous strain on both couples. While recognizing that payment ment is to vary from this basic understanding, should fairly reimburse the donor for her time, then it must be clear that the donor had been risk, and inconvenience, the reviewers also informed, and did not object to , this variance. Several years ago, a donor believed that icy that any recruitment organizations that wished she had donated her eggs to particular recipients to be listed on its website must agree to comply at a Texas fertility center but later learned that the with the compensation suggestions [18]. Ultimately, the fertility were all named defendants in an antitrust lawsuit program and its physician were found liable for, filed in California by an egg donor. The donor, among other things, failing to comply with their Lindsay Kamakahi, who also asks that she and agreement with the egg donor agency. Amid alleother similarly situated donors be certified as a gations of other misdeeds, the agency folded class, claims that the defendants engaged in shortly thereafter [16 ]. The case is still of which woman is the mother and, in some in preliminary stages [19 ]. The degree of information provided Recent Developments in Egg (whether eggs fertilized, whether a pregnancy Donation occurred, whether a child was born) varies. Hand in hand is the related topic of disclosure of his/ Technological advances over the past several her origins to the donor-conceived child. While years have given rise to reliably consistent results the decision is left to the discretion of the parents, in egg freezing, warming, and fertilizing, openmental health professionals and other experts ing new doors for women who wish to preserve continue to recommend disclosure at an approtheir own eggs for future use and for banking of priate age, but research suggests that parents, donated eggs. At least one state has modifier from the process, concluding that relirecently adopted a law governing the release of able research demonstrates that egg freezing, donor-identifying information to children. While with subsequent thaw and fertilization, works disclosure of identity is not mandatory, and the just as well as fertilizing fresh eggs [20 ]. As with law provides that the donor may opt out of disclomany innovations, egg freezing, particularly for sure, it is silent as to what entity shall serve as the donation, raises ethical and legal challenges for repository of donor information, how records are medical practices and banking organizations. Sperm banks now routinely protected; who would have access and how; ask their donors if they would consent to future would mandatory registration negatively impact contact by a child born from their donation, but the supply of donor eggs; where would such this practice has not been so commonly practiced information be housed; who would administer with egg donors. A direct contract between donor the registry; what would be the cost; and how and recipient (which can be prepared while would it be fundedfi At present, privately created preserving immediate anonymity) may address and managed registries such as the Donor Sibling this issue and provide a mechanism for such Registry perform this function, charging a regisfuture contact. However, medical practices that tration fee for recipients and donors, but particido not refer these patients for legal consult and pation in these arrangements is totally rely instead on their internal forms, usually an discretionary in most donor arrangements [23 ]. Fertility practices are encouraged to develop Implications for the Clinician written policies addressing these situations. Of course, future contact by a child assumes that the the overarching principle is that clinicians donor will then understand that a child has been should review and follow professional guidelines born of her donation, information that is typically in this area. Newest research in this dards of care, guidelines, although lacking real area, though, suggests that most donors would enforceability, are de facto standards of care like this information and that some practices now, against which practitioners will be judged. Even with permission by recipients, do share the outin light of the current threat imposed by the loom2 Oocyte Donation: Legal Aspects 37 ing egg donor class action suit [19], this principle (c) Benefits and risks and the likelihood of remains solid. Informed Consent for Egg Donation Additional areas of discussion for the intended Participants parent participant include: 1. The amount and complexavailable from the current provider ity of information to be offered and discussed 3. Adoption and foster care as alternatives to process primarily, although not exclusively, deals family-building through fertility treatment with risks to the patient. Living without children [24] risks pertain to the primary patient, to the potenthe medical aspects of each particular fertility tial offspring and to the donor patient, whose treatment are complex and involve steps that are behavior is outside the control of the primary extraordinary in most realms of patient care. However, certain core elements are essential to any informed consent process, including It is reasonably anticipated that eggs banked for for the egg donation patient: donation might not actually be provided to the 1. The physician, not a physician-designee, coneventual recipients/intended parents until, ducts the informed consent discussion. The consent should occur after a review of the giving rise to a host of practical and liability conessential elements, including: cerns. Center for Disease Control [Internet], cited October ment should be based on her time, inconvenience, 27, 2012. The New York State Task Force on Life and the Law those eggs should not be based on number of eggs Assisted reproductive technologies: analysis and recthat they will receive. The baby business: elite eggs, designer genes, refiect clinic expenses, such as storage, laboratory and the thriving commerce of conception. Boston: fees, and the payment to the donor (apportioned Harvard Business School Press; 2006. Repetitive oocyte donation, donors continues to grow, as does the technology: Fertil Steril [Internet]. However, developing treatpdf, and Practice Committee of the American Society ments are burdened with the responsibility of for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive extra diligence, measured application, and careTechnology. Recommendations for gamete and ful disclosures to patients about their risks and embryo donation, Fertil Steril [Internet]. Offices for Human Reproduction, 760 edge, and attitudes about the use of their oocytes and N. Baltimore: ete and embryo donation: a committee opinion, Fertil the Johns Hopkins University Press; 2010. Applegarth removal of ovaries, poor egg or embryo quality, Introduction recurrent miscarriage often stemming from chromosomal deficiencies, and advanced In the past 30 years, advances in reproductive maternal age. In the midthe focus of this chapter is to provide a 1980s, these advances subsequently led to the review of historical and current literature use of donated oocytes, enabling many infertile pertaining to psychosocial aspects of oocyte women and their partners, as well as single donation and to describe the psychological and males and homosexual male couples, to counseling issues that may arise for both become parents. Oocyte donation has no identifying information and with whom addresses a number of female medical condithe family will have no contact before, during, tions, including primary ovarian insufficiency or following the donation process. Applegarth others, is stressed, with the goal of benefiting all both medically and psychologically.