by draimee
Inconceivable
Feb 14 2011 in Dr. Aimee by draimee
Carolyn and Sean Savage’s joy turns to disbelief when they learn that a rare mistake at a fertility clinic left Carolyn pregnant with someone else’s child. This is an inspiring story of love and courage.
You can visit their website here: http://inconceivablebook.com/
You may have missed Friday’s episode of Dateline.  The story isn’t new but many of us are talking about it again because both couples have written books about what happened to them. And the most recent book was written by the couple who carried the other couple’s baby. If you missed the episode you can watch it here:
http://www.msnbc.msn.com/id/21134540/vp/41517579#41517579
The couple whose embryo was transferred to Carolyn Savage already wrote a book. You can go to their facebook page here: http://www.facebook.com/Misconception.Morell
Many of my patients as a result of all the media exposure have been asking me, “Will you make sure nothing like this happens to me?”
This is what you should know:
Embryo mix-ups are extremely rare. Ask your IVF Doctor what she does to prevent mix-ups.
This is what we do:
In the operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date.  As soon as the follicles are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is doubly checked with the patient’s record which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.
This story has a happy ending: Click here to read more. The Savages are now expecting twins via a surrogate: http://abcnews.go.com/Health/carolyn-sean-savage-embryo-mix-now-expect-twins/story?id=13318708
And don’t forget to attend the chat on Monday April 11th with Carolyn Savage right here.
Carolyn Savage said on February 17, 2011
Dr. Eyvazzadeh, Thank you for addressing this issue. It means a lot to Sean and I that clinics are paying attention and revisiting their protocols. I would caution you, however. I have read your description of the protocol you follow (provided above) and can tell you that an identical protocol was in place at our clinic and was followed. It is the same protocol as what you describe. The mistake occured when the wrong embryos were removed from cryopreservation and then labeled with all of our information. The complete details of the “hole” in our clinic’s protocol that allowed me to end up pregnant with someone else’s genetic child are located in the afterword of our book. It is imperative that you and your colleagues review what happened carefully.
The above offered safety protocol would not have prevented what happened to me.
Sincerely,
Carolyn Savage
Dr. Aimee Eyvazzadeh said on February 17, 2011
Dear Carolyn,
I’m honored that you would take the time to reply to my blog. You’re an amazing woman and I’m so supportive of all you’re doing to protect couples in this country from medical errors especially from IVF errors.
I don’t know the details of your case but I do know that what happened to you would not happen in the labs that I use for several reasosn: the checks and double checks are always in place and there are always 2 embryologists that check dishes to double check labels. The straws in which the embryos are cryopreserved are not discarded and there is a system in which 2 embryologists check the straw id with the dish id and we are hypervigilant about labeling dishes and checking them against paperwork and straw ID numbers.
Sentinal events such as what happened to you don’t usually involve a simple error such as what you describe. It’s usually a sequence of events. I am in no way saying that you’re wrong about what happened to you. I am saying that it usually involves more than someone mislabeling a dish. You may agree that if someone mislabeled a dish, the protocol was not followed and there were several steps that were missed that allowed a mislabeled dish to go anywhere near your thawed embryos.
I’m a huge advocate of you and all you’re doing.
Cristine Allen, TS (AAB) said on February 18, 2011
As a lab supervisor and with over 10 years of experience in the IVF lab, I have to agree 100% with you, Aimee. This is an extremely rare case of a sequence of mistakes that happened to these couples. Such happening is securely prevented by the folowing of strict protocols from agencies as AAB, ASRM, COLA, etc. and usualy a clinic that suffer this kind of unfortunate situation tends to be put out of business by the FDA, since ONE single mistake would never lead to such a great consequence. There are usually many mistakes involved in it as a sequence and they tend to be consistant errors, repeated several times, until one day things turn out like this. On this case, it seems like a misread straw that became a mislabeled dish that was maybe not checked with the names on the paperwork. For how many days in a roll?? How many embryologists manipulated this case? How many people checked this before transfering the embryos? Was it “avoidable” by strict protocols?… Unfortunatelly, probably could, but no one can tell for sure.
Can it happen to any infertility practice? More or less. It really depends on the administration of the lab. Does a lab that have strict safety protocols have less chance of it to happen? Yes, MUCH LESS. So what happens that could possibly make a lab to leave room for this kind of “mistake”?
Well, understaff is a major problem, since it leads to rush and consequent lack of attention. Unexperienced embryologist are another major problem. Since there is no strict requirements in US for an embryologist to touch your embryos, some labs hire fresh-from-college biologists calling them embryologists and letting it go with the flow (cheap and fast way to hire staff). Another problem that can also cause failure of the security system is called “toxic work environment”, (MBA guys love this term) where stress takes over the technologists capacity of concentration and dedication as a whole group due to great failure of the administration system.
Well, real unfortunate errors can also happen, no one is 100% human error-free, one would say… Yes, I agree…
Airplanes fall too.
Nuclear power plants blow out as well.
Your mother in law can come and leave with you too.
Nevertheless, not often such tragedies happen…
Insurance companies know that, right?
Again, it’s neeed a sequence of mistake, none of them catched timely for a devastating situation like that to happen. As per the other comment, 2 cases of errors leading to serious consequences, in many thousands of IVF cases, happened in UK . US have even more strict quality assurance rules than UK. I also agree 100% that 2 is 2 too many. Most US clinics are still on 0 for their trouble-counting and hopefully will keep this way.
At the end of the day, the chances of a couple to have their embryos misplaced can be a matter of choice on where they are going for treatment. It does take only a little bit of ressearch to rule out some places, specially if they have been involved with FDA problems or frequent law suites. Checking if your doctor and embryologists are liscenced and/or hold professional certifications is also a good tip.
But will it happen to you, coulpes looking for IVF treatment in reliable clinics?? In my humble opinion, NO, IT WON’T.
Erika Tabke said on February 17, 2011
Unfortunately, “rare” is still very devastating and life-altering for those unlucky enough be the rare ones.
After several high-profile mix-ups a few years ago, the UK’s Human Fertilisation and Embryology Authority (HFEA) decided to start publishing statistics on errors.
The UK’s Human Fertilisation and Embryology Authority (HFEA) just announced that 182 IVF errors or potential errors were reported in UK infertility clinics in 2007-2008. Eight of those were of the most serious grade, A; of those eight, two involved mix-ups where the wrong embryo or the wrong gametes had been used. (From http://www.ivfconnections.com/forums/content.php/283-Staggering-Number-of-IVF-Incidents-Reported)
Two in a year in the UK is two too many. And since we don’t track errors (or report them) the same way in the U.S., who knows how many are made here? The U.S. does three times as many cycles as the UK (in 2007, about 133K in the US versus 43K in the UK).
cory said on February 20, 2011
this couple was annoying in that all they did was complain about how they felt robbed giving up the baby they carried to his biological parents…..how was this different than the surrogate who carried their baby giving it up to them? i mean it was NEVER THEIR BABY but they acted like they should be able to keep it, yet they themselves should no better since they too used a surrogate. how would they feel if someone did this to them, so while I understand it would be difficult, i felt like they felt more sorry for themselves than just treat it as carrying another person’s baby for 9 months.
Dr. Aimee Eyvazzadeh said on February 20, 2011
Dear Cory,
We are on this earth to find love and one of the greatest loves a human can experience is love for a child. This couple gave the Morrell family one of the greatest gifts someone could have given anyone. They carried the Morrell’s baby to term and handed the baby over to the biological parents. Amazing.
They have not succeeded in being able to have another baby of their own. As of now they have not been successful with a surrogate.
They were robbed of the opportunity to have another child of their own. I haven’t heard them complain once. They are telling their story and it is truly inspiring. Inspiring because they aren’t complaining. Inspiring because they did the right thing for another couple.