Fillable Semen Production Form Semen samples must be collected (Academic medical center at State University of New York at Stony Brook)

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Semen Production Form Semen samples must be collected (Academic medical center at State University of New York at Stony Brook)

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Semen Production Form
Semen samples must be collected by masturbation into a sterile, 4.5 ounce, screw-cap, wide-mouthed specimen
container. This can be obtained from Island Fertility or any pharmacy. Samples must be collected using masturbation
unless you have already obtained a semen collection device with instructions from our office. Intercourse without a semen
collection device is prohibited. Condoms should not be used to collect the sample, as they are usually spermicidal
Specimens will not be accepted for diagnostic semen analysis without 2-7 days prior abstinence, you will have to
reschedule.
1. P
rint your first and last name and time of collection on the collection container label.
2. Open the sterile specimen container, breaking the sterile seal, and place the lid upside down.
3. Wash hands thoroughly.
4. Rinse the head of the penis, foreskin retracted, with water.
5. Do not use soap or water as a lubricant; only sterile mineral oil (which we will provide upon request) may be used.
6. Ejaculate into the specimen cup without touching the interior.
7. Replace the lid and close tightly.
8. Wash hands.
9. Fill out the Semen Production Form.
10. Carry the specimen and the completed form to the Andrology Laboratory Drop Off Window. Samples will not be
accepted without government issued photo ID. Unattended specimens will be discarded.
Male Name:
DOB:
Male Signature:
Female Name:
DOB:
Purpose of today’s visit to the laboratory (circle all that apply):
Process for insemination Process for IVF Analysis Cryopreservation
Date:
Time:
Production Location: Off-site Office
Was the entire sample collected?: Yes No
Days of abstinence:
Method of Collection: Masturbation Collection Device Other
Any illness/fever in the last 3 months? If “Yes,” please specify: Yes No
List any medications you are/have been on in the last 3 months:
Specimen Identification (For Office Use Only):
Date/Time:
ID Type/Number
Signature:
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Semen Production Form Semen samples must be collected (Academic medical center at State University of New York at Stony Brook)

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Completed 27 August 2020

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