by Jim Mayfield, Sonicu, jmayfield@sonicu.com

The recent back-to-back failures at two US fertility clinics are beyond stunning and have resulted in the loss of thousands of frozen human embryos. The breakdowns, which occurred in separate clinics in Cleveland and San Francisco, were apparently unrelated but nevertheless expose both the wonder and the fragility of this technology.

In the first case, the temperature unexpectedly rose inside a liquid nitrogen storage tank at University Hospitals’ Ahuja Medical Center fertility center in Cleveland on March 4 and compromised up to 2,000 eggs and embryos, according to initial hospital statements. That estimate was low, unfortunately, and updated to 4,000 in letters mailed to 950 affected patients in late March. “We are heartbroken to tell you that it’s unlikely any are viable,” the hospital said. Prior to the letter, the Washington Post had reported that temperatures had increased at the top of the tank but stayed at proper levels in its lower portion, raising the hopes of many patients.

The malfunction occurred sometime between Saturday afternoon and Sunday morning when the facility was not staffed. A remote alarm should have alerted support staff to the change in temperature but it had been turned off at a still undetermined time. The facility had been having difficulty with a liquid nitrogen automatic fill setting on its tank. It had received a backup tank but had not yet begun to transfer specimens.

For several days prior to the failure, hospital staff had been manually filling the tank, at times borrowing liquid nitrogen from other hospital labs. “The liquid nitrogen levels in the tank were monitored and appeared to be appropriate on Friday and Saturday,” the hospital said in its letter, “but we now suspect that may not have been the case.”

In the second case—which occurred on the same day—a senior embryologist at the Pacific Fertility Clinic in San Francisco noticed that the nitrogen level in a storage tank was very low during a routine check of the tanks. The clinic has been tight-lipped about the incident, but news reports indicate that some 500 patients were affected. The number of compromised eggs has not been disclosed.

Three concerns stand out from these incidents: the limitations of local alarming, the necessity of multi-level tank monitoring and the urgency for real-time data.

Local alarms, or on-premises alarms, are only beneficial if someone is present to hear them and respond. Absent a staff presence, a local alarm is meaningless. There are several market solutions available to help improve protection at fertility clinics, animal research facilities, cryogenic labs and health systems across the country where irreplaceable embryos and bio-samples are stored. Sonicu is among the market providers.