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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Very rare
Alerting signals, symptoms, evidence of occurrence: 
Only one embryo was obtained after an emergency IVF procedure for fertility preservation, that by mistake was not frozen on the usual day according to protocol. An adapted freezing procedure for later freezing should have been used but unfortunately this was not done.
Demonstration of imputability or root cause: 
Preservation process error.
Groups audience: 
Suggest new keywords: 
freezing protocol
lab error
IVF (in vitro fertilization)
Suggest references: 
TRIP annual report 2009 Tissue Vigilance
Expert comments for publication: 
Emergency IVF are made in oncologic patients, before chemotherapy or radiotherapy, to preserve fertility. There is usually short time, because patients have to start antineoplastic therapy. Ovarian stimulation is started at the beginning of menses, and, after oocytes retrieval, oocytes or embryos are frozen. Often this is the last opportunity for some oncologic patients who start a very toxic therapy to have some years later a pregnancy, because some antineoplastic therapies induce an irreversible damage to the ovaries. In this case, after an ovarian stimulation, the patient hasn't any embryos to freeze, and maybe she hasn't enough time to start another treatment before the beginning of antineoplastic therapy.