The report shows that 1,679 mistakes were made in UK fertility
clinics between 2010 and 2012. This figure adds up to an average of 500
to 600 incidents per year out of the 60,000 IVF cycles conducted annually.
Among the mistakes were three grade A incidents, the most
serious adverse incidents. One such incident was a mix-up involving sperm samples. The
family who sought IVF treatment intended to use donor sperm to have a genetically related sibling. Instead, they were given sperm from a different donor,
resulting in the child having a different genetic father to their sibling.
Another grade A incident concerned the contamination of the embryos
of 11 patients with 'cellular
debris', possibly sperm. The third grade A incident occurred when a member of
staff removed frozen sperm from storage prematurely.
There were also 714 grade B incidents, which includes loss of
embryos and cases where the quality of the patient's embryo has been affected
by malfunctioning equipment. 815 grade C incidents were reported, mostly
involving processing mistakes that cause patients' eggs to be unusable.
Over half of all incidents reported were categorised as
clinical, the majority of which involved either incidences of ovarian hyperstimulation syndrome or a failure to follow clinical protocols set out by
the HFEA's Code of Practice.
Sally Cheshire, chair of the HFEA, said:
'We are committed to ensuring that clinics provide the safest and highest
quality service to their patients. These results show that, in the main,
clinics are doing a good job of minimising the number of serious errors, and
this should be welcomed'.
However, Cheshire also noted the high number of grade C
incidents such as breaches of confidentiality: 'Clinics can and should be
eradicating these sorts of avoidable errors, which will go a long way towards
reducing patient distress and improving the overall experience of IVF
'These mistakes may be less serious at first glance but they
can still be very upsetting', she added.
'While we do what we can to ensure IVF is error free,
mistakes do sometimes happen, as they do in any area of medicine. What's most
important is learning the lessons from errors made to minimise the chance of
their happening again — this is not about naming and shaming'.