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HFEA releases 2014 incidents report

21 September 2015

By Dr Mary Yarwood

Appeared in BioNews 820

The Human Fertilisation and Embryology Authority (HFEA) has released its second annual report into adverse incidents at fertility clinics in the UK, showing a slight reduction in the overall number of reported problems following fertility treatment.

Of a total of 465 incidents reported to the HFEA in 2014, two were classified as grade A, the most serious, with 166 grade B incidents and 232 at grade C. Grade B incidents include events such as the loss of a patient's embryos and breaches of confidentiality.

One of grade A incidents involved a patient who became pregnant with twins after an embryo affected by chromosomal translocation was transferred, despite undergoing screening for the genetic condition using PGD. The woman was undergoing IVF treatment at CARE Fertility Nottingham, which used a third party laboratory, Genesis Genetics Europe (GGEu), to test the embryos.

The equipment used by GGEu, however, failed to detect the genetic defect before the embryo was implanted. It was later discovered when the woman underwent chorionic villus sampling (CVS). The HFEA's investigation concluded that the incident arose because of a 'recognised but rare failure of the testing technology', adding that there was 'no evidence of human error and/or weakness in the testing laboratory's systems and processes'.

CARE Nottingham has reported six of the seven adverse incidents relating to PGD misdiagnosis reported since 2009, minutes from an HFEA Licence Committee meeting reveal, including an incident in which GGEu misinterpreted test results, leading to a baby being born with neurofibromatosis type 1 (reported in BioNews 785). The HFEA's investigation into the latest incident found no evidence of systematic failings or that the clinic's practices are unsuitable.

The second grade A incident took place at South East Fertility Clinic in February 2014. Seven patients treated on the same day had egg collection with successful fertilisation, but staff later noticed that the embryos did not develop as well as they were expected to. Assessors from the HFEA concluded that the embryos were probably placed in petri dishes with 'sub-optimal media'. No pregnancies resulted from the treatment and the clinic offered the patients affected another cycle of treatment free of charge.

The total incidents reported represents approximately one percent of the 60,000 treatments carried out by UK fertility clinics each year. Nonetheless, the HFEA has urged clinics to concentrate on reducing the number of category B and C errors, which it says are avoidable in most cases and could be prevented.

Sally Cheshire, Chair of the HFEA, said: 'The small reduction in incidents is a step in the right direction but more can and must be done by clinics, and we can help.

'Since our last report, we have worked with clinics to improve their systems and practices... It is for clinics now to step up and make the necessary changes so that everyone affected by assisted reproduction receives the best possible care.'

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