Worksheet Template Portrait

Patient Information
Cycle Number
Fresh
Oxford Fertility Unit Charges – 1st April 2014
or
Frozen
Patient Sticker
Name of CCG Funding
Patient Sticker
Signature of staff to
confirm criteria met
STAFF USE ONLY
Tick if Cycle
NHS Funded
STAFF USE ONLY
Tick if
performed
NHS Funding
STAFF USE ONLY
Tick if Required
STAFF USE ONLY
Tick if
performed
Consultations
IVF or IVM
Treatment
Medical Consultation
£190
Nurse Planning Consultation
(includes ultrasound scan)
£215
IVF cycle
£3400*
IVM cycle (including ICSI)
£2370*
* These charges include all ultrasound scans & oestrogen blood tests, egg collection under sedation, laboratory costs,
embryo culture to day 3, embryo transfer, one pregnancy scan, follow up medical consultation if within 3 months, one
counselling session
Other IVF
Charges
ICSI
£1130
Blastocyst culture
£515
HFEA Licence Fee
£75
Embryo Glue
£155
EmbryoScope©
£415
Use of Donor Sperm in an IVF cycle
£505
Cyst Aspiration under sedation
£260
Embryo Transfer under sedation
£260
IMSI
£415
Assisted Hatching
£515
Endometrial Scratch
£235
Patient Information
Oxford Fertility Unit Charges – 1st April 2014
Endometrial Scratch under sedation
Other Fertility
Treatments
Other Fertility
Charges
£490
Drugs for IVF
£900-£1900
Drugs for IVM
£105
Gynaecological or Early Pregnancy Scan
£185
HyCoSy
£395
Ovulation Induction cycle (OI)
£465
Frozen Embryo Replacement cycle (FER)
£930*
Intra-Uterine Insemination cycle (IUI)
£1290*
Use of Donor sperm
£505
Drugs for FER/OI
£300-£500
* These charges include all ultrasound scans, laboratory costs, embryo replacement (FER), one pregnancy scan,
HFEA licence fee for FER.
PGS/PGD
Biopsy procedure for PGS/PGD samples
£1130
PGS – aCGH (analysis of up to 8 embryos)
£2270*
Additional analysis (per embryo)
£325
PGD – price on application
*This charge does not include embryo freezing and subsequent replacement cycles if required.
Genetic
Testing
DNA Fragmentation Analysis of sperm
£415
Sperm Aneuploidy (5 chromosome test)
£620
Y-Chromosome Micro-Deletion blood test
£260
Semen Analysis
£180
SSR (Surgical Sperm Retrieval)
£955
Andrology
(NB- does not include freezing and storage costs)
Freezing
Charges
Reviewed
06.02.14
Embryo Freezing (inc. first year storage)
£760
Subsequent Annual Embryo / Sperm / Egg
Storage (by Direct Debit)
£285
© 2013 Oxford Fertility Unit
FAE 
Price List 2014 v1
Page 2 of 5
Patient Information
Oxford Fertility Unit Charges – 1st April 2014
Egg Sharer
Costs
Embryo Freezing (inc. 3 years storage)
£1560
Embryo Freezing (inc. 10 years storage)
£4365
Sperm Freeze (inc. first year storage)
£390
Sperm Freeze (inc. 3 years storage)
£1185
Sperm Freeze (inc. 10 years storage)
£3580
Subsequent Sperm Freezing per sample
£235
Supplement for Slow (Day 3) Freezing
£225
Egg Sharer cycle (IVF)
No charge*
Egg Sharer cycle (ICSI)
£1135*
If Egg Sharing does not proceed
£1030*
* These charges include all ultrasound scans and oestrogen blood tests, drugs for the IVF cycle, egg collection under
sedation, laboratory costs, embryo culture to day 3, embryo transfer, one pregnancy scan, follow up medical
consultation if within 3 months, one counselling session.
Egg / Embryo
Recipient
Treatment
Egg/Embryo Donation Registration
£695 – nonrefundable
Egg Donation Recipient Trial cycle
£570
Egg Donation Recipient IVF cycle
£8035*
Egg Donation Recipient ICSI cycle
£9170*
Embryo Recipient cycle
£3605*
* These charges include all ultrasound scans & oestrogen blood tests, laboratory costs, embryo transfer, one
pregnancy scan, one counselling session.
Other Charges
Recipient Drugs
£250-£400
HFEA Licence Fee
Patient from
Overseas
£75
IVF cycle
£8755*
* These charges include all pre-treatment appointments, ultrasound scans & oestrogen blood tests, drugs for the IVF
cycle, egg collection under sedation, laboratory costs, embryo transfer, one pregnancy scan, follow up medical
consultation if within 3 months, one counseling session
Oxford IVI
IVI Egg Recipient Cycle
£8240*
*These charges include all medical consultations once treatment commences, ultrasound scans & blood tests, drugs for
the cycle, laboratory costs, ICSI, embryo transfer, BHCG blood test, pregnancy scan(s), one counseling session and a
follow up medical consultation. It does not include the cost of transporting frozen sperm to Spain.
Reviewed
06.02.14
© 2013 Oxford Fertility Unit
Price List 2014 v1
Page 3 of 5
Patient Information
Oxford Fertility Unit Charges – 1st April 2014
Blood
Tests
Female Hormone Profile
£190
(FSH, LH, Testosterone, Prolactin, TSH, AMH)
Male Hormone Profile
£120
(FSH, LH, Testosterone, Prolactin, TSH)
Reviewed
06.02.14
FSH
£45
LH
£45
AMH
£70
TSH
£45
Prolactin
£45
Oestrogen
£45
Progesterone
£60
Testosterone
£45
Female Thrombophilia
£475
Beta hCG
£45
HIV, Hepatitis B (all) & Hepatitis C
£185
Hepatitis B antigen
£80
Hepatitis B core antibody
£65
Hepatitis C
£70
HIV
£45
CMV
£80
Rubella
£45
Syphilis
£45
Karyotyping
£275
Cystic Fibrosis
£170
Blood Group/Rh
£45
© 2013 Oxford Fertility Unit
Price List 2014 v1
Page 4 of 5
Patient Information
Oxford Fertility Unit Charges – 1st April 2014
Other Services
Counselling Sessions
£85
Copy of medical records
£50
Refunds
Refunds may be made if a cycle is cancelled or abandoned for medical reasons.
The following amounts are retained by the Unit from the initial payment.
Cancellation of IVF cycle before egg collection
Cancellation of IVM cycle before egg collection
Cancellation of an FER cycle
Cancellation of PGS/aCGH
Cancellation of IUI
£660
£260
£200
£260
£250
In the event that we are unable to collect any eggs at egg collection a refund of £500 will be made.
How to pay:
Payment can be made by credit card/debit card or by cash, in person or over the telephone. Please note we
are unable to accept American Express cards.
Our prices are reviewed annually in line with the financial year. Please note that if you book for treatment after 1st
April 2015 prices may have changed.
I confirm the above costs have been explained to me.
Patient Signature………………………….. Date……………………..
Print Name…………………………..
Patient Signature………………………….. Date……………………..
Print Name…………………………..
Clinic Signature……………………………Print Name………………………………Date…………….
One copy to remain in notes and one copy to be retained by the patient
Reviewed
06.02.14
© 2013 Oxford Fertility Unit
Price List 2014 v1
Page 5 of 5