Letter of Agreement

We(insert name and department of institution or medical group) herby indicateour intention to join theNational Physicians Cooperative (NPC)of the Oncofertility Consortium®. Specifically, we will participate in research studies to preserve fertility for men, women and adolescents with medical conditions in which treatment or the condition itself will likely result in the loss of fertility. We will contribute fresh and frozen ovarian and/or testicular tissue (as instructed by the Oncofertility Consortium®National Physicians Cooperative Leadership Committee)as described in the protocolsto the Oncofertility Consortium®at Northwestern University. We will also have the option to participate in additional multicenter studies as they become available. We affirm that we areable to enter into this agreement on behalf of our institution and/or medical group. We agree to terms outlined below for participation in theNPC and Oncofertility Consortium®.

The following conditions relate to our membership in the National Physicians Cooperative of the Oncofertility Consortium®, in general. We acknowledge and agree to the following:

  1. We will perform experimental procedures under IRB approved protocols and obtain informed consent. This provision includes any fertility preservation procedure that is deemed experimental by the American Society for Reproductive Medicine (ASRM) such as ovarian and testicular tissue cryopreservation.
  2. We will follow American Society of Clinical Oncologist (ASCO) guidelines for advising patients of the range of options available to them for fertility preservation and utilize the most mature technology that is appropriate for a given patient based on her age, timeline to treatment, medical condition and personal wishes.
  3. We understand and agree that all NPC and Oncofertility Consortium®documents, protocols, procedures, logos, promotional materials, reagents, formulas etc. are considered proprietary and confidential and may not be shared with anyone outside of the NPC.
  4. Decisions about clinical care are the sole responsibility of the individual physicians and member sites. We will defend, indemnify and hold the National Physicians Cooperative and the Oncofertility Consortium® harmless in any actions or threatened actions or investigations (including medical malpractice and professional liability actions) regarding our clinical judgment, clinical care or tissue banking practices.

The following conditions relate to our participation in the NPC research studies. We acknowledge and agree to the following.

We have been asked to participate in the NPC because we see patients who wish to preserve their fertility for medical reasons. These patients include those diagnosed with cancer or with a chronic disease (example: rheumatoid arthritis, lupus, etc.), which may lead to infertility itself or through its treatments. We may limit the age of patients treated at our center as we see fit or as determined by our IRB.

We are interested in NPC research studies relating to (please check all that apply):

_____ Men______Women_____ Children

  1. We agree to provide IRB approved versions of any NPC protocols, consents and the approval letters for each of our procedures on initial approval and with each continuing review or amendment. We agree to make any revisions requested as needed within the time period specified.
  2. We will not harvest or prepare any tissues for use by the NPC without IRB approval in advance. We will also not harvest or prepare ovarian or testicular tissue on protocols other than those approved by the National Physicians Cooperative and Oncofertility Consortium®.
  3. We understand and agree that,under the terms of this study,research ovarian tissue is contributed (as described in the protocol) to the Oncofertility Consortium®at Northwestern University and testicular tissue is contributed (as described in the protocol) to the University of Pittsburgh.The research use of this tissue(either fresh or frozen) will be determined by the Oncofertility Consortium®National Physicians Cooperative LeadershipBoard according to the priorities of the Oncofertility Consortium®grant projects, and the suggestions and proposals received by the Oncofertility Consortium®National Physicians Cooperative LeadershipBoard.

Benefits and Risks to Program: We understand and agree that:

  • We will receive consultation regarding establishing a fertility preservation program.
  • We understand that neither we,nor the patient, will receive any compensation for participation in NPC research studies.

We have read, understand and agree with the terms listed above and understand that additional study specific information is available on the Oncofertility Consortium® website. We understand that we may withdraw from participation in the NPC and the Oncofertility Consortium® at any time by written notice to the Director of the Oncofertility Consortium® and that we will return any NPC materials that we have obtained and still be bound by the Oncofertility Consortium® Agreement.

We understand that we can direct any questions to the Director, Mary Ellen Pavone, MD,by contacting the NPC coordinator, Brigid M. Smith, at or (312)503-2506.

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Signature for Insert InstitutionDate

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Signature for National Physicians CooperativeDate

Mary Ellen Pavone, MD, MSCI

Director, National Physicians Cooperative

NPC: Letter of Agreement, Version dated1/9/2015

Please view disclaimer here: oncofertility.northwestern.edu/disclaimer