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Cleveland Fertility Clinic Still Unsure What Caused Storage Tank Failure

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About 950 patients now have to deal with the consequences of what the University Hospitals Cleveland Medical Center calls a “catastrophic failure” at their fertility clinic.

In a March 26, 2018 letter to patients, the center acknowledged that over 4,000 eggs and embryos were lost after a storage tank that normally kept the materials cold malfunctioned and became too warm.

The letter was a follow-up to the initial announcement, which the center released on March 8, 2018. At that time, it was still unclear how many eggs and embryos were affected.

Fertility Tank Failed

Cleveland Fertility Clinic Investigates Storage Tank Failure

In their first announcement, it was clear that the center didn’t know exactly what had caused the failure. They stated only that there was an “unexpected temperature fluctuation” with the tissue storage bank over the weekend of March 3-4, and that they were unsure of the viability of the eggs and embryos that were stored in nitrogen inside.

The center launched an investigation and according to their most recent letter, they still don’t have the “ultimate answer” as to why this happened. For what is still an unknown reason, the temperature in the storage tank started to rise and continued to rise above the temperature necessary to keep the eggs and embryos viable.

The center initially thought the tank malfunction affected about 2,000 eggs and embryos, involving about 700 patients. That number has now been changed to over 4,000 eggs and embryos and about 950 patients.

Mistakes Made that Led to Tragedy

What the medical center has determined so far is that a number of mistakes were made, including the following:

1) The alarm didn’t go off.

The tank was equipped with an alarm that was supposed to go off if the temperature started to rise to dangerous levels. That alarm did not go off as expected. The investigators discovered that it had actually been turned off, though they don’t know when. As a result, employees were never alerted to the danger. “We don’t know who turned off the remote alarm,” the center stated in their letter, “nor do we know how long it was off, but it appears to have been off for a period of time. We are still seeking those answers.”

2) The storage tank needed maintenance it hadn’t received.

The center admitted that prior to the tank failure—and actually for several weeks—they had experienced problems with the liquid nitrogen automatic fill. To solve this problem, the tank manufacturer had instructed the center to remove all the eggs and embryos and “thaw” out the tank. This is a process that was expected to take several weeks to complete. The center had begun this process when the malfunction occurred, but had not yet transferred any eggs or embryos.

3) The nitrogen levels may have been off.

Because the automatic nitrogen fill was not working, employees were manually filling the tank. Levels seemed to be correct on Friday and Saturday, but now investigators think that something could have gone wrong with the nitrogen fills. Whether that caused the rise in temperature is still unclear.

These failures should not have happened,” the letter reads. The center has now brought in outside experts to help answer the remaining questions.

Hundreds of Families Affected by the Clinic’s Mistakes

The human toll of this tragedy is just beginning to come to light. The New York Times reported on one father who had frozen his sperm before undergoing chemotherapy in 2003. He later had a child with his wife through in vitro fertilization. The couple had planned to go through the process again to give their son a sibling, but now they aren’t sure how to move forward.

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