IVFWales Response To Stories In The Press
As you are probably aware there is a news story running at the moment about an incident that occurred at IVFWales in 2007. We have some concerns that there are some inaccuracies which we have not had the opportunity to correct and these may be worrying to our patients.
Firstly we would like to say that we deeply regret this incident and have apologised sincerely to both couples, and have admitted complete liability.
What exactly happened?
This incident occurred in 2007. The conditions in the laboratory at the time were quite challenging, with unusually high numbers of patients. There were very high noise levels from pile driving during building work just outside the windows, which was also causing vibration, making working down the microscope very difficult. Additionally, work was being carried out in artificial lighting due to hospital lighting faults. Had we had several weeks’ warning, we may have been able to cancel cycles, but under the circumstances, we had to go ahead with treatment.
This resulted in a moment’s distraction, which unfortunately resulted in the incident. Due to the protocols that we had in place however, the mistake was discovered immediately, and the couple involved in the transfer were informed. Following counselling they agreed that the embryo that had just been placed in the cavity of the womb, should be prevented from implanting, thus ensuring that no pregnancy occurred. Within 30 minutes, the first couple who had undergone the embryo transfer had received tablet treatment to prevent implantation. Implantation would normally take place about a week later.
The embryo, no smaller than the tip of a needle, had just been thawed from the freezer after 5 years in storage, following a successful pregnancy. As there was no pregnancy following the error, there was not a termination as reported.
Why was there a delay in talking to the second couple?
The second couple meanwhile had been informed that their embryo had been lost due to an accident, as at that point in time we had not obtained permission from the first couple to talk about their treatment to the second couple. The second couple were therefore asked to return the following day, when they were given the full explanation, including the reason why we had delayed telling them. Both couples were offered counselling and support.
What happened next?
Following the incident 2 enquiries were immediately set up to look at the causes of the incident - internally by the Trust, and externally by the HFEA. All recommendations have been implemented, including improvement in laboratory conditions, reducing activity so safe numbers of cycles are planned, and a review of the witnessing protocols.
What is witnessing?
Witnessing is the process which follows the embryos through every step of their progress in the laboratory. Prior to the incident 2 embryologists would witness at the time but if also undertaking a second task, would sign later. By adding a time to the witnessing form, the second embryologists would now stop what they were doing and sign immediately - thus ensuring better witnessing. We have undertaken a continuous audit of our full compliance with this new protocol which has been reported to the HFEA.
This should reassure any couples going through treatment now that our processes are as good as anywhere in the UK, and for those couples who have had treatment in the past, the fact that the incidnet was detected immediately shows that an error of this nature could not go undetected.
What are the ‘Near Misses’ that have also been reported?
As a centre, we have had a very open reporting culture for reporting “Near Misses” to the HFEA – this means that small administrative errors which could lead to more serious incidents are disseminated around other centres – so all centres can learn and improve from other clinics. The 2 previous near misses in 2006 with regard to witnessing and ID that we reported to the HFEA and to which the press are referring, were in fact the following:
• An incident where 2 women had the same name, and the wrong set of notes was sent to the laboratory- the lab noticed due to the routine checking against 3 identifiers (name, date of birth and hospital number) and sent the notes back.
• The second incident occurred when the wrong patient ID sticky label was placed on a patient information sheet - again this was noted immediately and the labels corrected.
Neither of these patient ‘Near Misses’ were in relation to patient treatment though as a clinic we feel that lessons can be learnt from minor incidents so that they do not progress into a major incident.
Finally we would like to say that we really appreciate all the support that we have had not only from the HFEA and the Trust, but also from the couples that undergo treatment here, and we apologise if you have been caused anxiety due to this incident. Please feel free to phone if you need more reassurance, or discuss things at your next clinic appointment.
Our 2009 IVFWales New Year Newletter has been added to the Web site. Click the icon to access it.
Human Fertilisation & Embryology Published Figures (8 October 2008)
As you may be aware the 2006 live birth rate figures were today released onto the HFEA website. IVFWales success rates for 2006 are currently being completed and validated (as stated on the HFEA website) and are currently published as incomplete data. The figures for 2006 will be entered onto the website in January 2009 once these have been agreed and signed off by the Unit. The 2007 pregnancy rates for IVF Wales are available under the tab 'Success Rates' on the HFEA website. Also see our most current results on this website www.ivfwales.co.uk/results.asp.
Vitrification
Following the implementation of the Vitrification programme at IVFWales in August 2007, we are delighted by our current pregnancy rate. The new technique eliminates the presence of ice during freezing and therefore results in excellent survival rates during 'thawing'. In the first 39 couples to undergo Vitrified embryo transfer, 98% of embryos fully survived compared to the 50-80% survival that has been experienced globally for the last 3 decades. Our results which were presented at the British Fertility Society conference in Liverpool in September 2008 mirror those of other groups in Japan, Canada and the U.S who are also using the technique.
The photos show an embryo before vitrification and also in a drop of Vitrfification solution on the tip of a 'CryoLeaf'.
We are located on the 1st floor, C block in the largest hospital in Wales, University Hospital of Wales, Cardiff. Our current £1.4 million clinic opened in September 2007.
We are a consultant led service with many years expertise in IVF treatment to ensure you the highest quality of care.
Our new laboratories and treatment areas are equipped with the latest and most advanced technology available.
IVFWales functions as both a secondary and tertiary referral centre, offering both NHS and self-funding treatments to couples having difficulty conceiving. Our aim is to provide a comprehensive range of investigations and infertility treatments. These are provided in a relaxed, friendly atmosphere and delivered in a non-judgemental way. We continually strive to maintain the highest quality of care and treatment to maximise your chance of success.
Look out for further developments and new treatments on the web site in the coming months.