Misconception - Book Review

Misconception - Book Review

October 29, 2010
1

Authors: Paul and Shannon Morell
Published in 2010 by Howard Books, New York

In 2009 we read in the popular press that a woman in Michigan was mistakenly implanted with another woman’s embryos due to a mix up at an unnamed IVF Clinic. While this type of mistake is rare, the story was further sensationalized by the revelation that the pregnant woman, Carolyn Savage, intended to carry the pregnancy to term and then turn the baby over to its rightful parents, Shannon and Paul Morell. This was a heartwarming and wonderful outcome from an error that likely would have ended up in tragedy in any other situation.

I finished reading the book less than a week after it was published because I’m keenly interested in the events that led to an error like this. I believe that there is much to be learned from the mistakes of others and I encourage open discussion with the embryologists at PFC to see if it would be possible for us to make a similar mistake. Unfortunately however, the book shares few details of what exactly happened that caused one woman’s embryos to be placed in the uterus of another. We do know that both women used the same last name (Shannon Morell had been treated under her maiden name, Savage), and the error resulted from the thawing of frozen embryos, rather than from the use of fresh embryos. Additionally, we know that Carolyn Savage reported to the clinic for her frozen embryo transfer and somehow the embryos from Shannon Morell (Savage) were thawed and transferred. We do not know if the wrong orders were sent to the IVF lab (“thaw Shannon Savage’s embryos”), if the embryos were inappropriately labeled in the freezer, or if the embryologist simply was not paying attention and thawed the wrong embryos. Whatever the error, it seems likely that having the same last name somehow contributed to the problem.

Regardless of the error that led to thawing the wrong embryos, my opinion is that the major mistake happened when the embryologist went into a room with embryos from one patient and handed them over to another patient. That moment of transfer is the final checkpoint for error prevention. The embryologist is absolutely responsible for confirming that the patient in the room is the owner of the embryos that are to be transferred.

Therefore, even though the book does not share many details about the source of the error, in my opinion, the mistake was made by the embryology laboratory staff. A similar mistake happened in the UK in 2007. In that particular case, the pregnant woman terminated the pregnancy. The Morell’s were aware of this history and worried that the same fate awaited them. All of their frozen embryos had been thawed. Even though the Morells had 2 beautiful daughters, Ellie and Megan, they had planned on using every one of their embryos. Both couples were deeply religious and much is made of this in the book, from praying for a positive outcome to discussions on the embryo as a human being. The book tells a deeply human story and will likely be an emotional rollercoaster for any readers who have undergone fertility treatments.

The book is rich with information on how patients approach, cope with and understand fertility treatments. Shannon Morell appears to have been a typical patient, but with deep religious convictions and a belief that life begins at fertilization. As a sideline to the story concerning the mix-up, she also delves into the story of one of her other embryos that did not make it to transfer or freezing. She was upset that an embryo remaining after an embryo transfer in an earlier treatment cycle was not frozen for later use. Chances are that this embryo had either arrested or was not of sufficient quality to tolerate freezing and thawing. This issue could have been resolved earlier if she had spoken with the MD or embryologist at the time, but she was not aware until much later that the embryo had not been frozen. Similarly, in the pregnancy that is the focus of the book, six embryos were thawed but only three were transferred. Little if any information seems to have reached Shannon on the fate of the other three. It is very likely that these three embryos did not survive, as the freezing technology in use at that time was not as good as what we use today. Understandably with this lack of information, the Morell’s were left with a feeling that mistakes were happening. In sharing their story with the media, they reasoned that perhaps the publicity would force other fertility clinics to be more careful about how they handle embryos, and think twice about the ramifications of their mistakes.

Being that medical care, including fertility treatment, is provided by humans to other humans, it is inevitable that random mistakes will happen in fertility clinics, medical offices, hospitals and every other workplace. However, the more we talk about them, study them and increase awareness, the less likely they are to be repeated. At PFC, we study all these cases in great detail, to see what we can learn, to find out if we are vulnerable to similar errors, and to modify our processes to ensure that we cannot make the same mistake. Unfortunately, with many of the errors that have occurred in IVF clinics, the staff appear to wait until the patient has had a pregnancy test to determine whether the embryo(s) have implanted, before disclosing the error. To me, this delay appears a further insult to the patients involved, since it may remove some of their options for remedy (such as taking the morning after pill to prevent the embryo from implanting). The gamble the clinic is taking is that the patient will not become pregnant and then perhaps the error will not seem so bad, or worse still, not be disclosed at all. The proper path is to fully disclose any mistake immediately after it happens, so that all parties can make fully informed decisions and have as many choices as possible. Mistakes, like secrets, only get worse with time, not better. And they never go away. Waiting makes mistakes worse, suggests deceit, and potentially ruins the lives of one or more families.

At PFC we have never had an embryo mix-up incident, and we have never inseminated a patient’s oocytes with the wrong sperm. In our laboratory, we have procedures in place that require a double witness of these and other critical steps in the IVF process. We are also very diligent about personally checking each patient’s identity when sperm or eggs come into the laboratory, and when embryos leave. Additionally, we review all our processes on a regular basis and look for new ways to improve. Interestingly, both the College of American Pathologists (our accrediting agency) and more recently the FDA, now specifically assess our procedures and processes for identifying and tracking gametes and embryos and our ID checks on patients. In fact, the FDA conducted an unannounced inspection here at PFC this summer specifically to look at this area of our practice, and we passed with flying colors. PFC will continue to demand improvements in our protocols and procedures, so that we will continue to avoid errors and continue to provide the same quality of care that we have given for the last 10 years.

Comments

By Carolyn Savage
November 01, 2010
Dear Dr. Conaghan, Thank you for taking the time to write about our unfortunate situation. I do want you to know that the error that led to the transfer of Logan Morell into my uterus was caused by multiple people inside and outside of the embryology lab. We are not at liberty to release the details of exactly what happened, yet. However, early next year a detailed, step by step accounting of exactly what caused the mistake and how it was discovered will be made public. (How it was discovered is even more unsettling than the original error.) In the meantime, please know that we have suffered profoundly as a result of what happened. I understand that escaping human error is impossible, but the prevention of such a devastating mistake is easy through professional vigilance and diligence. Every employee in every fertility clinic must be diligent. Protocols should be reviewed often, and every step of patient protection should be strictly followed. More to come. Please continue your wonderful writing. I know as an infertility patient I scour every resource to try and come up with a solution to our infertility diagnosis. I truly appreciate professionals of your caliber taking the time to write. Information is a wonderful thing for patients. Thank you! Carolyn Savage

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