Risk management in IVF

Electronic witnessing in the medically assisted reproduction laboratory: insights and considerations after 10 years of use

STUDY QUESTION

What have we learnt after 10 years of electronic witnessing?

SUMMARY ANSWER

When applied correctly, an electronic witnessing system can replace manual witnessing in the medically assisted reproduction lab to prevent sample mix-up.

WHAT IS KNOWN ALREADY

Electronic witnessing systems have been implemented to improve the correct identification, processing, and traceability of biological materials. When non-matching samples are simultaneously present in a single workstation, a mismatch event is generated to prevent sample mix-up.

STUDY DESIGN, SIZE, DURATION

This evaluation investigates the mismatch and administrator assign rate over a 10-year period (March 2011-December 2021) with the use of an electronic witnessing system. Radiofrequency identification tags and barcodes were used for patient and sample identification. Since 2011, IVF and ICSI cycles and frozen embryo transfer cycles (FET) were included; IUIs cycles were included since 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The total number of tags and witnessing points were recorded. Witnessing points in a particular electronic witnessing system represent all the actions that have been performed from gamete collection through embryo production, to cryopreservation and transfer. Mismatches and administrator assigns were collected and stratified per procedure (sperm preparation, oocyte retrieval, IVF/ICSI, cleavage stage embryo or blastocyst embryo biopsy, vitrification and warming, embryo transfer, medium changeover, and IUI). Critical mismatches (such as mislabelling or non-matching samples within one work area) and critical administrator assigns (such as samples not identified by the electronic witnessing system and unconfirmed witnessing points) were selected.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 109 655 cycles were included: 53 023 IVF/ICSI, 36 347 FET, and 20 285 IUI cycles. The 724 096 used tags, led to a total of 849 650 witnessing points. The overall mismatch rate was 0.251% (2132/849 650) per witnessing point and 1.944% per cycle. In total, 144 critical mismatches occurred over the different procedures. The yearly mean critical mismatch rate was 0.017 ± 0.007% per witnessing point and 0.129 ± 0.052% per cycle. The overall administrator assign rate was 0.111% (940/849 650) per witnessing point and 0.857% per cycle, including 320 critical administrator assigns. The yearly mean critical administrator assign rate was 0.039 ± 0.010% per witnessing point and 0.301 ± 0.069% per cycle. Overall mismatch and administrator assign rates remained fairly stable during the evaluated time period. Sperm preparation and IVF/ICSI were the procedures most prone to critical mismatch and administrator assigns.

LIMITATIONS, REASONS FOR CAUTION

The procedures and methods of integration of an electronic witnessing system may vary from one laboratory to another and result in differences in the potential risks related to sample identification. Individual embryos cannot (yet) be identified by such a system; this makes extra manual witnessing indispensable at certain critical steps where potential errors are not recorded. The electronic witnessing system still needs to be used in combination with manual labelling of both the bottom and lid of dishes and tubes to guarantee correct assignment in case of malfunction or incorrect use of radiofrequency identification tags.

WIDER IMPLICATIONS OF THE FINDINGS

Electronic witnessing is considered to be the ultimate tool to safeguard correct identification of gametes and embryos. But this is only possible when used correctly, and proper training and attention of the staff is required. It may also induce new risks, i.e. blind witnessing of samples by the operator.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was either sought or obtained for this study. J.S. presents webinars on RIW for CooperSurgical. The remaining authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Catastrophic Human Error in Assisted Reproductive Technologies: A Systematic Review

OBJECTIVE

Assisted reproductive technologies (ARTs) are complex processes with multiple and diverse opportunities for human error. Errors in ART are thought to be rare, but can have devastating consequences for patients and their offspring. The objectives of this article are to review known cases of human error in the ART laboratory and suggest preventative strategies.

METHODS

We performed a systematic review of the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using PubMed and Google Scholar databases. Studies were eligible for inclusion if they involved known cases of unintentional human error in the ART laboratory. Only full-text articles in English were included. References of the resulted studies were considered for inclusion.

RESULTS

A total of 420 articles were screened and 37 articles were selected for inclusion. These largely included case reports and reviews in the medical and legal literature. Twenty-two adverse events due to human error in the ART laboratory were identified. Eight of these adverse events were the result of the insemination with the wrong sperm, 6 errors lead to the transfer of the wrong embryo, 3 lead to an error in preimplantation genetic testing, and 5 adverse events lead to the failure of gamete and embryo cryostorage.

CONCLUSIONS

Since the advent of ART, there have been reports of catastrophic events occurring secondary to human error in the laboratory to include incidents of unintended parentage, and have resulted in the loss of embryos and gametes through cryostorage failure. Proposed solutions include the stringent implementation and adherence to safety protocols, adequate laboratory staffing and training, and novel methods for specimen labeling and tracking. Of utmost importance is having knowledge of these errors and the ability to determine cause so that future events can be prevented.

Evaluating risk, safety and efficacy of novel reproductive techniques and therapies through the EuroGTP II risk assessment tool

STUDY QUESTION

Can risks associated with novelties in assisted reproduction technologies (ARTs) be assessed in a systematic and structured way?

SUMMARY ANSWER

An ART-specific risk assessment tool has been developed to assess the risks associated with the development of novelties in ART (EuroGTP II-ART).

WHAT IS KNOWN ALREADY

How to implement new technologies in ART is well-described in the literature. The successive steps should include testing in animal models, executing pre-clinical studies using supernumerary gametes or embryos, prospective clinical trials and finally, short- and long-term follow-up studies on the health of the offspring. A framework categorizing treatments from experimental through innovative to established according to the extent of the studies conducted has been devised. However, a systematic and standardized methodology to facilitate risk evaluation before innovations are performed in a clinical setting is lacking.

STUDY DESIGN, SIZE, DURATION

The EuroGTP II-ART risk assessment tool was developed on the basis of a generic risk assessment algorithm developed for tissue and cell therapies and products (TCTPs) in the context of the project 'Good Practices for demonstrating safety and quality through recipient follow-up European Good Tissue and cells Practices II (EuroGTP II)'. For this purpose, a series of four meetings was held in which eight ART experts participated. In addition, several tests and simulations were undertaken to fine-tune the final tool.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The three steps comprising the EuroGTP II methodology were evaluated against its usefulness and applicability in ART. Ways to improve and adapt the methodology into ART risk assessment were agreed and implemented.

MAIN RESULTS AND THE ROLE OF CHANCE

Assessment of the novelty (Step 1), consisting of seven questions, is the same as for other TCTPs. Practical examples were included for better understanding. Identification of potential risks and consequences (Step 2), consisting of a series of risks and risk consequences to consider during risk assessment, was adapted from the generic methodology, adding more potential risks for processes involving gonadic tissues. The algorithm to score risks was also adapted, giving a specific range of highest possible risk scores. A list of strategies for risk reduction and definition of extended studies required to ensure effectiveness and safety (Step 3) was also produced by the ART experts, based on generic EuroGTP II methodology. Several explanations and examples were provided for each of the steps for better understanding within this field.

LIMITATIONS, REASONS FOR CAUTION

A multidisciplinary team is needed to perform risk assessment, to interpret results and to determine risk mitigation strategies and/or next steps required to ensure the safety in the clinical use of novelties.

WIDER IMPLICATIONS OF THE FINDINGS

This is a dynamic tool whose value goes beyond assessment of risk before implementing a novel ART in clinical practice, to re-evaluate risks based on information collected during the process.

STUDY FUNDING / COMPETING INTEREST(S)

This study was called EUROGTP II and was funded by the European Commission (Grant agreement number 709567). The authors declare no competing interests concerning the results of this study.

Prospective risk analysis adjusted to the reality of clinical and fertility laboratory processes

Prospective risk analysis (PRA) is a valuable instrument in quality assurance. The practical application of PRA in clinical laboratories according to the method we have described elsewhere leaves room for a number of adaptations to make it more applicable to and consistent with actual laboratory processes.

We distinguished between more and less critical tests and products in the laboratory processes and scored the consequences of failures at different steps in line with the previously described failure type and effect analysis (FMEA) method. PRA was carried out for two typical laboratory processes: standard clinical laboratory testing and the cryopreservation of semen.

Tests in standard clinical laboratory in processes were labeled critical, semi-critical or non-critical. Consequence scoring (C) and assessed risk (R) were significantly higher for processes containing tests considered to be critical (C=6.6±1.5, R=19.3±13.5) as compared to processes containing tests considered semi- or non-critical (C=3.0±1.4, R=8.2±5.3 and C=3.2±1.8, R=8.6±5.9, respectively). There were no differences in the C and R scores for processes with tests considered semi- or non-critical. In the semen cryopreservation process, a distinction between the processes involving private semen and generally accessible semen was made. The C scores for these were significantly different (C=5.9±2.2 and 5.0±2.0, respectively), the R scores did not differ.

Introduction of a test criticality classification for the purpose of consequence scoring led to an improved PRA methodology, better reflecting the reality of clinical laboratory practice. We found that two levels of criticality, critical and less critical, were sufficient to achieve this improvement.