Wrong donor sperm used in fertility clinic error

There has been a rise in the number of mistakes at UK fertility centres, with the wrong donor sperm used in one case, a report says.

The study, from the Human Fertilisation and Embryology Authority (HFEA), showed that incidents are rare – affecting less than 1% of fertility treatment cycles – but have risen 6% over the last year and 18% in three years.

An increasing proportion of mistakes are serious, causing severe or moderate harm to patients.

Some of the increase is down to fertility clinics improving reporting of their errors, the HFEA said.

The data shows that, in 2018/19, there were 606 incidents, of which two were the most serious, grade A, and 294 were grade B.

The 606 is up 6% from 571 incidents the year before and an 18% rise from 514 in 2015/16.

Grade A incidents involve severe harm to one person, such as death or being implanted with the wrong embryo, or they involve major harm to many people, such as a frozen storage unit containing the embryos of many patients failing.

Grade B incidents involve serious harm to one person, such as the loss or damage of embryos, or moderate harm to many people, such as sensitive personal data about more than one patient being sent to the wrong recipient.

Some 56% of all grade A and B incidents reported to the HFEA are when something has clinically gone wrong.

In one grade A incident, an embryologist failed to verify the donor sperm process at the point of preparing laboratory records, resulting in the wrong sperm being used.

In another case, the incorrect gas cylinder was delivered and connected, which damaged the embryos of several patients.

The HFEA said that, overall, it believes fertility treatment is becoming safer, with the quality of care improving across UK clinics.

Around 80% of clinics were issued with a full licence, confirming that most are meeting expected standards and performing well, it said.

The overall number of non-compliances per inspection has decreased each year since 2015/16 and over half of clinics had fewer areas of concern compared with their previous inspection.

Multiple births, the single biggest health risk from IVF, are also at an all-time low of 10%.

Overall, there were 351 non-compliances in 2018/19, down from 457 in 2015/16.

However, the HFEA said there was some room for improvement, with more non-compliances relating to medicines management being classed as major and critical.

There were 37 non-compliances in this area in 2018/19, of which six were critical and 24 were major, up from a total of 25 the year before.

On infection control, there were 25 in 2018/19, up from 15, and there were 11 non-compliances for legal parenthood, up from six.

Legal parenthood consent is essential to enable the patient’s partner to become the legal parent of any children.

Sally Cheshire, chairwoman of the HFEA, said: “I’m pleased that this report indicates continued good performance across the UK fertility sector.

“Significant improvements in some of the key areas we’ve highlighted previously with clinics are especially reassuring, proving that working together with clinics and the professional bodies is having a positive impact for patients.

“One area that we focused on during the last year is patient engagement and experience, so I’m particularly pleased that more than 75% of inspections found no non-compliances in this area and that we are moving in the right direction.

“It’s good news that clinics have reduced the number of minor incidents, but we’re concerned that any incident is one too many.

“We will continue to ensure that the whole sector learns from any clinic incident, however minor, to understand what went wrong and, crucially, that steps are taken to ensure it does not happen again.”

Gwenda Burns, head of operations at Fertility Network, welcomed the report but said there was “room for improvement in these statistics”.