Form 0920-0556 National ART Surveillance System (NASS) [screen captures

NASS Log-In Web Page

Optional NASS 2.0 Cycle Worksheet
This optional worksheet has been developed for clinic staff to use if they wish when preparing to report federally-mandated
ART cycle data through the National ART Surveillance System (NASS) website. Prior to entering data online in NASS, clinic
staff may choose to transfer relevant information onto this worksheet from the medical records of patients on whom they
are required to report. This worksheet matches the questions and order of the NASS 2.0 website. You may print and make
copies of this worksheet at your clinic.
Please note that your clinic must still enter (or import) all required data into the NASS 2.0 website and complete the
submission process online in NASS. Please do NOT send hardcopies of any completed worksheets.
If you have any questions about this worksheet, please contact the NASS Help Desk at:
1-888-650-0822 or by e-mail at NASS@Westat.com.

IMPORTANT NOTICE ABOUT USING THIS SECTION
This section is optional for use solely at the clinic to ensure that NASS worksheet data are for the correct patient.
Information on this page is not collected in NASS and is not reported to CDC.
Patient First Name:___________________________________________________________________________
Patient Middle Initial/Name:____________________________________________________________________
Patient Last Name: ___________________________________________________________________________
Patient Clinic ID/Medical Record Number:_________________________________________________________
Donor or Gestational Carrier: ___________________________________________________________________
Clinic ID/Medical Record Number: _______________________________________________________________

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

INITIAL REPORTING PAGE
PATIENT PROFILE SECTION
NASS patient ID |__|__|__|__| - |__|__|__|__| - |__|__|
Patient optional identifiers
Optional identifier 1 |__|__|__|__|__|__|__|
Optional identifier 2 |__|__|__|__|__|__|__|
Patient date of birth (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Sex of patient
⃝

⃝

Female
Male

Patient ethnicity
⃝

NOT Hispanic or Latino
⃝

Refused

⃝

Hispanic or Latino
⃝

Unknown

Patient race (select all that apply)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
(OR)
Reason race not reported
Refused
⃝

Unknown
⃝

Cycle start date (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
RESIDENCY SECTION
At the start of cycle, is patient residency primarily in U.S.?
⃝

Yes
⃝

Refused

No
⃝

U.S. state of primary residence |_______________________________________________________|
U.S. city of primary residence |________________________________________________________|
U.S. zip code of primary residence |____________________________________________________|
Country of primary residence |_________________________________________________________|

(continued next page)
Optional NASS 2.0 Cycle Worksheet v.Aug_2024

INITIAL REPORTING PAGE (continued)
INTENT SECTION
Intended type of ART (select all that apply)
IVF: Transcervical
GIFT: Gametes to tubes
ZIFT: Zygotes to tubes or TET: tubal embryo transfer
(OR)
Oocyte or embryo banking

[IF IVF/GIFT/ZIFT] Intended embryo source (select all that apply)
Patient embryos
Intended oocyte source and state for FRESH patient embryos (select all that apply)
PATIENT fresh oocytes
DONOR fresh oocytes
PATIENT frozen oocytes
DONOR frozen oocytes
Intended oocyte source and state for FROZEN patient embryos (select all that apply)
PATIENT fresh oocytes
DONOR fresh oocytes
PATIENT frozen oocytes
DONOR frozen oocytes
DONOR unknown (select only if oocyte source is unknown)
Donor embryos (donated from another patient’s IVF cycle)
FRESH donated embryos
FROZEN donated embryos
[IF BANKING] Banking type (select all that apply)
Embryo banking
Autologous oocyte banking
Donor oocyte banking
[IF EMBRYO BANKING] Intended source for embryo banking (select all that apply)
Embryo banking from autologous oocytes
Embryo banking from donor oocytes
[IF EMBRYO BANKING] Intended duration of embryo banking (select all that apply)
Short term (≤12 months)
Delay of transfer to obtain genetic information
Delay of transfer for other reasons
Long term (>12 months) banking for fertility preservation prior to gonadotoxic medical treatments
Long term (>12 months) banking for other reasons
(continued next page)
Optional NASS 2.0 Cycle Worksheet v.Aug_2024

INITIAL REPORTING PAGE (continued)
[IF AUTOLOGOUS OR DONOR OOCYTE BANKING] Intended duration of oocyte banking (select all that apply)
Short term (≤12 months)
Long term (>12 months) banking for fertility preservation prior to gonadotoxic medical treatments
Long term (>12 months) banking for other reasons
Intended sperm source (select all that apply)
Partner
Donor
Patient, if male
(OR)
Unknown (select only if all sperm sources unknown)
Intended pregnancy carrier
⃝

Patient
⃝

None (oocyte or embryo banking cycle only)

Gestational carrier
⃝

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

ART PERFORMED PAGE
Type of ART performed (select all that apply)
IVF: Transcervical
GIFT: Gametes to tubes
ZIFT: Zygotes to tubes or TET: tubal embryo transfer
(OR)
Oocyte or embryo banking

[IF IVF/GIFT/ZIFT] Embryo source (select all that apply)
Patient embryos
Oocyte source and state for FRESH patient embryos (select all that apply)
PATIENT fresh oocytes
DONOR fresh oocytes
PATIENT frozen oocytes
DONOR frozen oocytes
Oocyte source and state for FROZEN patient embryos (select all that apply)
PATIENT fresh oocytes
DONOR fresh oocytes
PATIENT frozen oocytes
DONOR frozen oocytes
DONOR unknown (select only if oocyte source is unknown)
Donor embryos (donated from another patient’s IVF cycle)
FRESH donated embryos
FROZEN donated embryos

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

REASON FOR ART PAGE
Reason for ART (select all that apply)
Male infertility
Medical condition
Genetic or chromosomal abnormality (specify) |________________________________________________________|
Abnormal sperm parameters
Azoospermia, obstructive
Azoospermia, non-obstructive
Oligozoospermia, severe (<5 million/mL)
Oligozoospermia, moderate (5-15 million/mL)
Low motility (<40%)
Low morphology (4%)
Other male factor (specify) |________________________________________________________|
History of endometriosis
Tubal ligation for contraception
Current or prior hydrosalpinx
Communicating
Occluded
Unknown (current or prior hydrosalpinx)
Other tubal disease (not current or prior hydrosalpinx)
Ovulatory disorders
Polycystic ovaries (PCO)
Other ovulatory disorders
Diminished ovarian reserve
Uterine factor
Preimplantation genetic testing (including aneuploidy screening) as reason for ART
Oocyte or embryo banking as reason for ART
Indication for use of gestational carrier
Absence of uterus
Significant uterine anomaly
Medical contraindication to pregnancy
Recurrent pregnancy loss (as indication for use of gestational carrier)
Unknown (indication for use of gestational carrier)
Recurrent pregnancy loss
Other reasons related to infertility (specify) |________________________________________________________|
Other reasons not related to infertility (specify) |________________________________________________________|
Unexplained infertility

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

FEMALE PATIENT HISTORY & PHYSICAL PAGE
Height
|__| Feet (AND/OR) |__|__| Inches (OR) |__|__|__|__| Centimeters
(OR)
Height unknown
Weight at the start of this cycle
|__|__|__|__| Pounds (OR) |__|__|__|__| Kilograms
(OR)
Weight unknown
Did the patient smoke during the 3 months before the cycle started?
⃝ Yes
⃝ No

⃝ Unknown

Any prior pregnancies?
⃝

Yes
If prior pregnancies reported and couple is not surgically sterile, enter months or years attempting pregnancy since last
clinical pregnancy
|__|__|__| months AND/OR |__|__| years
Number of prior pregnancies |__|__|
Number of prior full term births (live and stillbirths) |__|__|
Number of prior preterm births (live and stillbirths) |__|__|
Number of prior stillborn infants |__|__|
Number of prior spontaneous abortions |__|__|
Number of prior ectopic pregnancies |__|__|

⃝

No
If no prior pregnancies reported and couple is not surgically sterile, enter months or years attempting pregnancy
|__|__|__| months AND/OR |__|__| years

Number of prior stimulations for ART cycles

|__|__|

Number of prior ART cycles started with the intent to transfer oocytes or embryos |__|__|
[IF PRIOR ART AND PRIOR PREGNANCY] Did any of the prior ART cycles result in a live birth?
⃝ Yes
⃝ No

Maximum FSH level (MIU/mls) |__|__|__| . |__|__|
(OR)
FSH level unknown
Date of most recent AMH level (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Most recent AMH level (ng/mL) |__|__|__| . |__|__|
(OR)
AMH level unknown
Optional NASS 2.0 Cycle Worksheet v.Aug_2024

SOURCES & CARRIERS PAGE
OOCYTE SOURCE PROFILE SECTION
Youngest oocyte source
Patient
⃝

Donor
⃝

Oocyte source date of birth (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
(OR)
Age at earliest time oocytes were retrieved |__|__|
Oocyte source ethnicity
⃝

Not Hispanic or Latino
⃝

Refused

⃝

Hispanic or Latino
⃝

Unknown

Oocyte source race (select all that apply)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
(OR)
Reason race not reported
Refused
⃝

Unknown
⃝

PREGNANCY CARRIER PROFILE SECTION
Pregnancy carrier
⃝

Patient
⃝

None (oocyte or embryo banking cycle only)

Gestational carrier
⃝

Pregnancy carrier date of birth (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
(OR)
Age at time of transfer |__|__|
Pregnancy carrier ethnicity
⃝

Not Hispanic or Latino
⃝

Refused

⃝

Hispanic or Latino
⃝

Unknown

(continued next page)

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

SOURCES & CARRIERS PAGE (continued)
Pregnancy carrier race (select all that apply)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
(OR)
Reason race not reported
Refused
⃝

Unknown
⃝

SPERM SOURCE PROFILE SECTION
Specify sperm source (select all that apply)
Partner
Donor
Patient, if male
(OR)
Unknown (select only if all sperm sources unknown)
Sperm source date of birth (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
(OR)
Sperm source date of birth unknown
Sperm source ethnicity
⃝

Not Hispanic or Latino
⃝

Refused

⃝

Hispanic or Latino
⃝

Unknown

Sperm source race (select all that apply)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
(OR)
Reason race not reported
Refused
⃝

⃝

Unknown

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

STIMULATION & MEDICATIONS PAGE
STIMULATION & MEDICATIONS SECTION
Was there stimulation for follicular development?
⃝

⃝

Yes
No
[If YES, STIMULATION]
Was this a minimal stimulation cycle?
⃝
⃝

Yes
No

Oral medication such as aromatase inhibitor or selective estrogen receptor modulator used
Yes
⃝

Clomiphene dosage (Total mgs) |__|__|__|__|__| . |__|__|
Letrozole dosage (Total mgs) |__|__|__|__|__| . |__|__|
Other oral medication (specify) |________________________________________________________|
Other oral medical dosage (specify) |__|__|__|__|__| . |__|__|
⃝

No

Medication containing FSH used
Yes
⃝

Short-acting FSH (Total IUs)
⃝

|__|__|__|__|__| . |__|__|

No

Medication with LH/HCG activity used
⃝

⃝

Yes
No

Primary GnRH protocol used

⃝

⃝

⃝

⃝

No GnRH protocol
GnRH Agonist Suppression
GnRH Agonist Flare
GnRH Antagonist Suppression

(continued next page)

STIMULATION & MEDICATIONS PAGE (continued)
Optional NASS 2.0 Cycle Worksheet v.Aug_2024

CANCELLATION SECTION
Cycle canceled prior to retrieval?
Yes
⃝

No
⃝

Date cycle canceled (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Primary reason cycle was canceled
Low ovarian response
⃝
⃝

High ovarian response
⃝

Concurrent illness
⃝

Other (specify) |________________________________________________________|

⃝

Inadequate endometrial response
⃝

Withdrawal only for personal reasons

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

RETRIEVAL PAGE
FRESH OOCYTE RETRIEVAL SECTION
Date retrieval performed (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Number of patient oocytes retrieved |__|__|
Number of donor oocytes retrieved |__|__|
Use of retrieved oocytes (select all that apply)
Used for this cycle
Oocytes frozen for future use
Number of FRESH oocytes frozen for future use |__|__|
Oocytes shared with other patients
Embryos frozen for future use
COMPLICATIONS OF OVARIAN STIMULATION OR OOCYTE RETRIEVAL SECTION
Were there any complications of ovarian stimulation or oocyte retrieval?
Yes
⃝

No
⃝

[IF YES] Complications (select all that apply)
Infection
Hemorrhage requiring transfusion
Ovarian hyperstimulation requiring intervention or hospitalization
Medication side effect
Anesthetic complication
Thrombosis
Death of patient
Other (specify) |________________________________________________________|
Did the complication(s) require hospitalization?
⃝ Yes
⃝ No

SPERM RETRIEVAL SECTION
Sperm status
⃝

Fresh
⃝

Mix of fresh and thawed

Thawed
⃝
⃝

Unknown

Sperm source utilized
⃝

Ejaculated
⃝

Testis
⃝

Retrograde urine
⃝

Unknown

⃝

Epididymal
⃝

Electroejaculation
⃝

Donor

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

MANIPULATION PAGE
Intracytoplasmic sperm injection (ICSI) performed on oocytes?
⃝

All oocytes
⃝

No oocytes

⃝

Some oocytes
⃝

Unknown
[IF ALL OR SOME ICSI] Indication for ICSI (select all that apply)
Prior failed fertilization
Poor fertilization
PGT
Abnormal semen parameters on day of fertilization
Low oocyte yield
Laboratory routine
Frozen oocyte
Rescue ICSI
Other (specify) |________________________________________________________|

In vitro maturation (IVM) performed on oocytes?
⃝

All oocytes
⃝

No oocytes

⃝

Some oocytes
⃝

Unknown

⃝

Yes
⃝

Unknown

Pre-implantation genetic testing (PGT) performed on embryos?
No
⃝

[IF YES]
Total number of 2PN |__|__|
Reason for PGT (select all that apply)
Either genetic parent is a known carrier of a gene mutation or a chromosomal abnormality
Aneuploidy screening of the embryos
Elective gender determination
Other screening of the embryos
Technique used for PGT (select all that apply)
Polar Body Biopsy
Blastomere Biopsy
Blastocyst Biopsy
(OR)
Unknown
(continued next page)
Optional NASS 2.0 Cycle Worksheet v.Aug_2024

MANIPULATION PAGE (continued)
Assisted hatching performed on embryos?
⃝

⃝

All embryos
Some embryos
No embryos

⃝

Unknown
⃝

Was this a research cycle?
⃝
⃝

Yes
No
[IF YES] Approval code |________________________________________________________|

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

TRANSFER PAGE
TRANSFER ATTEMPT SECTION
Was a transfer attempted?
Yes
⃝
⃝

No
[IF NO] Primary reason no transfer was attempted
⃝

Low ovarian response
⃝

Failure to survive oocyte thaw
⃝

Concurrent illness
⃝

Unable to obtain sperm specimen
⃝

Other (specify) |________________________________________________________|

⃝

High ovarian response
⃝

Inadequate endometrial response
⃝

Withdrawal only for personal reasons
⃝

Insufficient embryos

GENERAL TRANSFER DETAILS SECTION
Date transfer performed (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Most recent endometrial thickness |__|__|mm
FRESH EMBRYO TRANSFER DETAILS SECTION
Number of fresh embryos transferred to uterus |__|__|
If only one fresh embryo was transferred to the uterus, was this an elective single embryo transfer?
Yes
⃝
⃝

No

[FOR EACH FRESH EMBRYO TRANSFERRED TO UTERUS]
Quality of embryo
⃝

Good
⃝

Poor

⃝

Fair
⃝

Unknown

Date of oocyte retrieval (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Was the oocyte used to create this embryo retrieved from a different clinic?
⃝
⃝

Yes
No
If yes, clinic name |_______________________________________________________|
Clinic city |______________________________________________________________|
Clinic state |_____________________________________________________________|

Number of fresh embryos cryopreserved |__|__|

(continued next page)
Optional NASS 2.0 Cycle Worksheet v.Aug_2024

TRANSFER PAGE (continued)
FROZEN EMBRYO TRANSFER DETAILS
Number of thawed embryos transferred to uterus |__|__|
If only one thawed embryo was transferred to the uterus, was this an elective single embryo transfer?
Yes
⃝
⃝

No

[FOR EACH THAWED EMBRYO TRANSFERRED TO UTERUS]
Quality of embryo
⃝

Good
⃝

Poor

⃝

Fair
⃝

Unknown

Date of oocyte retrieval (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Date embryo was cryopreserved (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Was the oocyte used to create this embryo retrieved from a different clinic?
⃝
⃝

Yes
No
If yes, clinic name |_______________________________________________________|
Clinic city |______________________________________________________________|
Clinic state |_____________________________________________________________|

Number of thawed embryos cryopreserved (re-frozen) |__|__|
GIFT/ZIFT/TET TRANSFER DETAILS SECTION
Number of oocytes or embryos transferred to the fallopian tube |__|__|

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

OUTCOMES PAGE
OUTCOME OF TRANSFER SECTION
Outcome of treatment cycle
⃝

Not pregnant
⃝

Clinical intrauterine gestation
⃝

Heterotopic

⃝

Biochemical
⃝

Ectopic
⃝

Unknown

[IF CIU OR HETEROTOPIC]
Maximum number of fetal hearts on ultrasound performed before 7 weeks or prior to reduction |__|__|
(OR)
No ultrasound performed before 7 weeks gestation or prior to reduction
[IF ULTRASOUND]
Ultrasound date with maximum number of fetal hearts observed before 7 weeks or prior to reduction (mm/dd/yyyy)
|__|__| - |__|__| - |__|__|__|__|
Any monochorionic twins or multiples?
⃝
⃝

⃝

Yes
No
Unknown

OUTCOME OF PREGNANCY SECTION
Outcome of pregnancy
⃝

Live birth
⃝

Stillbirth
⃝

Maternal death prior to birth

⃝

Spontaneous abortion
⃝

Induced abortion
⃝

Outcome unknown

Date of pregnancy outcome (mm/dd/yyyy) |__|__| - |__|__| - |__|__|__|__|
Source of information confirming pregnancy outcome (select all that apply)
Verbal confirmation from patient
Written confirmation from patient
Verbal confirmation from physician or hospital
Written confirmation from physician or hospital
Number of infants born |__|__|
Method of delivery
⃝

Vaginal
⃝

Unknown

Cesarean
⃝

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

BIRTH PAGE
BIRTH INFORMATION INFANT #1
Infant #1: Birth status
⃝

Live born
⃝

Unknown

Stillborn
⃝

Infant #1: Gender
Male
⃝
⃝

⃝

Female
Unknown

Infant #1: Weight
|__|__| Pounds AND |__|__| Ounces
(OR)
|__|__|__|__| Grams
(OR)
Weight unknown
Infant #1: Birth defects (select all that apply)
Cleft lip/palate
Genetic defect/chromosomal abnormality
Neural tube defect
Cardiac defect
Limb defect
Other (specify) |________________________________________________________|
(OR)
Birth defects unknown
(OR)
None

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

BIRTH INFORMATION INFANT #2
Infant #2: Birth status
⃝

Live born
⃝

Unknown

Stillborn
⃝

Infant #2: Gender
Male
⃝
⃝

⃝

Female
Unknown

Infant #2: Weight
|__|__| Pounds AND |__|__| Ounces
(OR)
|__|__|__|__| Grams
(OR)
Weight unknown
Infant #2: Birth defects (select all that apply)
Cleft lip/palate
Genetic defect/chromosomal abnormality
Neural tube defect
Cardiac defect
Limb defect
Other (specify) |________________________________________________________|
(OR)
Birth defects unknown
(OR)
None

Optional NASS 2.0 Cycle Worksheet v.Aug_2024

BIRTH INFORMATION INFANT #3
Infant #3: Birth status
⃝

Live born
⃝

Unknown

Stillborn
⃝

Infant #3: Gender
Male
⃝
⃝

⃝

Female
Unknown

Infant #3: Weight
|__|__| Pounds AND |__|__| Ounces
(OR)
|__|__|__|__| Grams
(OR)
Weight unknown
Infant #3: Birth defects (select all that apply)
Cleft lip/palate
Genetic defect/chromosomal abnormality
Neural tube defect
Cardiac defect
Limb defect
Other (specify) |________________________________________________________|
(OR)
Birth defects unknown
(OR)
None

(this page may be copied for additional infant births)

Optional NASS 2.0 Cycle Worksheet v.Aug_2024