Standards › Standard 8 › Policies
Policy · FRT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
At a glance
- Before treatment, each patient gets written and verbal information on the options, success rates, risks, costs and alternatives.
- Success rates are stated accurately, with the basis for the calculation.
- Consent is obtained for each stage, including handling, storage, use and future use or disposal of gametes and embryos.
- Consent can be changed or withdrawn, and the change is recorded.
- Stop and get help straight away if: treatment starts with no written information, or a stage starts with no consent for that stage.
1. Purpose
To make sure each patient understands and agrees to each stage of treatment, not one signature for all (8.1, 8.2).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Consent for fertility treatment is not one signature. Each stage, including the storage and use of gametes and embryos, needs its own informed decision, because each raises different questions.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Owns the policy and the success-rate statement | Clinician |
| Counsellor and nurse | Give the information and record the consent | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Inform.
- Give the written and verbal information on options, success rates, risks, costs and alternatives (FRT-FRM-001).
Key point: Written and verbal, before treatment.
Step 2. Consent by stage.
- Obtain consent for each stage separately, including what happens to any gametes and embryos (FRT-FRM-002).
Key point: Each stage, its own consent.
Step 3. Review.
- Review consent when the plan changes, and record any change or withdrawal.
Key point: Consent follows the plan.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Patients with written information before treatment | 100% | Monthly | Clinical director | Escalate to chief executive |
| Stages with consent recorded | 100% | Monthly | Clinical director | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| FRT-FRM-001 | Treatment information and options record | Record |
| FRT-FRM-002 | Stage-specific consent record | Consent |
| CON-SOP-001 | Informed consent before significant care | Consent |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Success-rate statement to follow the ESHRE add-ons good practice recommendations (2023). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Fertility & IVF Accreditation Training (AMB-13)
- Patient Identification, Informed Consent and Patient Rights (T-07)
- Healthcare Ethics for ASF Accreditation (A-07)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)