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Freezer malfunction at UH may lead to greater lab safety, industry expert says

March 10, 2018 GMT

Freezer malfunction at UH may lead to greater lab safety, industry expert says

CLEVELAND, Ohio -- The incident that may have damaged frozen eggs and embryos at University Hospitals Ahuja Medical Center is like an airplane crash: tragic, uncommon and likely to increase lab safety in the future, said Dr. Kevin Doody.

“We will all learn from it,” said Doody, immediate past president of the Society for Assisted Reproductive Technology. “We will all do a better job of ensuring this type of thing is not likely to happen again.”

The Society for Assisted Reproductive Technology is a professional organization for labs and doctors in this field, based in Birmingham, Alabama.

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University Hospitals notified about 700 fertility patients that frozen eggs and embryos may have been damaged over the weekend when the temperature rose in a storage tank. The affected liquid nitrogen freezer held about 2,000 eggs and embryos, some dating back to the 1980s.

The incident is still under investigation. The storage tank had off-site monitoring and an audible alarm that would alert staff to such a temperature change. The alarm was sounding on Sunday morning when staff arrived but there was no one in the facility overnight on Saturday. The tank was plugged into the hospital’s emergency power supply and was therefore hooked up to a generator, so it did not lose power.

Doody declined to speculate on what may have gone wrong. “It could have been any one of a variety of things,” he said.

While the UH program is under scrutiny, it’s important to know that there is not a set operating standard for fertility clinics in regard to alarms and safeguards, Doody said. “There’s no cookbook of how everybody should do it,” he said.

UH has not released details about how its lab operated, but Doody described practices in many fertility labs across the country.

Because labs housing frozen eggs and embryos are usually not staffed around the clock, alarm systems are in place to alert technicians when something is wrong. In cases involving a college-affiliated lab, the alarm signals campus police, who then contact lab staffers.

In Doody’s fertility clinic in Dallas, Texas, the trouble alarm automatically calls the cell phone of one of four embryologists on call. If the first lab staffer doesn’t answer, the alarm automatically calls the second, third and fourth person, if needed, on the list. The embryologist can determine what needs to be done to remedy the situation.

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An alarm company can be used to handle emergencies, but the company still needs to contact a lab worker who knows how to deal with the equipment, said Doody.

“You’re putting something else in the chain,” Doody said. “Is the alarm company going to know how precious [the frozen eggs and embryos] are? They may not.”

The freezer tanks used in assisted reproductive labs are very different from household refrigerators. They are cooled by liquid nitrogen, which is gaseous nitrogen that has been pressurized until it turns liquid. Most tanks are about the size of a household dishwasher.

There are two kinds of tanks used in assisted reproductive labs, Doody said. Some are vapor tanks that keep the specimens above the liquid nitrogen and cooled in the nitrogen’s vapor. Other types of tanks submerge the specimens underneath the surface of the liquid nitrogen.

Specimens need to be kept at temperatures below -140 Centigrade or -220 Fahrenheit.

Most freezer tanks do not have redundant alarms. “It’s uncommon that these things fail,” he said. Some labs conduct drills to be sure their alarms are working property, and perform manual checks of liquid nitrogen levels.

UH’s complete investigation into the incident will result in valuable information on how to improve lab safeguards, Doody said.

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