# Embryologist mistake at transfer



## Mogwai34 (Jul 25, 2015)

Hi All,

I'm currently on my 2ww of a FET after transferring 1 5CA blastocyst. I am 9dp5dt and tested early and have a bfn. Deep down I think I knew this had failed as I had a really traumatic transfer. 

On transfer day, the consultant struggled to fit the catheter. They don't do guided ultrasound transfer or mock transfer. Eventually the catheter was in place and the blastocyst was transferred but the embryologist said that it had been retained. It was then transferred for the second time. The embryologist checked the catheter and called "all clear" and the catheter was removed. 

I was concerned that this had impacted success rates so once it was transferred, I sought reassurance that it was definitely inside me. The consultant and embryologist were quite dismissive, saying yes, yes of course it is. The consultant then proceeded to tell me that I had about 30-35% chance of success etc and we spoke for a few minutes about success rates etc before I left the bed and went to the toilet to get dressed. Half way through getting dressed, a nurse entered the toilet telling me I had to come back and that the embryologist had found my embryo and it hadn't been transferred after all. 

I was completely shocked. How could this have happened?!! The Consultant walked in and told me to calm down. He said that they would have to place the embryo back in the culture medium for another 30 minutes or so to get it back to optimum conditions like before. He told a nurse to take me to a private room to have some space. 

During this time we were simply left in a consulting room alone. No one came to speak to us and I believe the consultant carried on with the remainder of the transfers. At one point I attempted to leave the room so that someone could update us and I was quickly ushered back inside by a nurse, as if to be quiet and not cause a scene in front of other patients. 

Eventually the consultant returned. I asked if there could have been any trauma to the embryo if it had been exposed to light and change of temperature and was told no. I asked what the rationale was for re-incubating and they said it was for "embryo protection." I don't know if this a good thing or bad thing but I certainly felt like we were pushed to the back of the queue while the other transfers were completed. We requested that two embryologists be present for the transfer to cross check whether the catheter was clear. 

We proceeded with the third transfer and both embryologists confirmed my blastocyst had transferred. 

I felt completely traumatised by this experience. I was in a lot of physical pain  but more than that was all the disappointment that our chances could have been ruined by failure to thoroughly check. I don't know what the protocol should be in a lab but I would have thought that there should always be two embryologists witnessing procedures to avoid errors. There had been only one.

Also, I feel that the embryologist should never have declared "all clear" if she hadn't completely checked and double checked. Apparently, my embryo was hanging to the side of the catheter and obscured by a bit of mucous. I understand that mistakes happen and we are all human. But I cant help but feel completely and utterly devastated that this oversight could have been prevented. 

We have had one successful cycle with this clinic which is why we decided to do our frozen cycle with them. However, I am also being treated with immune treatment elsewhere as there is a lot that our clinic does not agree with and they don't offer individualised treatment plans. 

We have one more blastocyst stored with them. I really don't know what to do next. I'm not sure how to move on from this feeling that this mistake could have been prevented. They were adamant that this didn't ruin my chances in any way, but how can they be certain and were they just protecting themselves? I feel so devastated that we have a negative test. If this hadn't have happened and we had a negative test, it would have been easier to bear as I could just tell myself that I did everything I could and it wasn't meant to be. I cant stop thinking about it and I'm even dreaming about it at night. 

Does anyone have any similar experiences (Im assuming and hoping this is a rare occurrence!)or does anyone know about protocol, such as whether 2 embryologists should be present for good practice? I don't know whether to raise a complaint or whether I have to accept that there are risks with all procedures and that it couldn't have been helped. I also don't know whether I should move my remaining embryo or just accept what happened and do our final cycle with them...….

Thanks for reading xx


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## chini (Sep 26, 2017)

Hi Mogwai, I'm really sorry to read your story and how the clinic let you down. It sounds like something that should have never happened. It also sounds to me that you did everything you could in that situation, so please at least don't blame yourself.

I had something similar happen to me during our first and only NHS cycle. The transfer was going on and the person doing the transfer seemed to have a lot of trouble with it. So I asked which side (right or left) she was using, as I have a vaginal septum... only to hear her then reply that she didn't know about the septum!!! So she hadn't bothered to read my notes before starting the procedure! I was so shocked I completely zoned off from outrage from that point onwards. I remember as through a cloud them declaring the cathether was empty (there were two people doing the transfer in my case), but feeling totally numb about it all in the light of the massive mess up and lack of care they had just revealed. But I had a very similar feeling to you - that the cycle won't work because they had no clue what they had done with the poor little embryo. And indeed it didn't work. In hindsight it has to be said there were also other factors, such as them failing to diagnose my adenomyosis as well as the lack of thyroid and immune support which I've added after that.

So when we moved to the Lister my first request was that I get a dummy transfer before anyone attempts doing a transfer, and so that who ever does my transfer will know whether they're on the right or the left side and will be able to answer my questions should I have any. And that's what they did - and I had the exact same team doing my real transfer that had done the mock transfer. So the second time when it didn't work at least I knew it wasn't about the transfer as the transfer had been done very carefully.

I would recommend to you whether you stay at your current clinic or change clinics that you request to have a dummy transfer before your next cycle. Also, I would raise the question of why they had such a hard time finding the right "path"? Maybe you have some anatomical issue which should be investigated more closely (it could be e.g. a partial septum, they're surprisingly common) before another transfer is attempted. A saline scan conducted by a skilled professional should be able to reveal more - e.g. Clinical Diagnostics have a very pro guy Bill Smith doing scans whom you can turn to if you don't trust your clinic to be specialised enough.

But also give yourself time to grieve. You're heartbroken and it's good to seek answers and think what you can do differently next time, but it's also important to be kind and merciful to yourself and take time to just be and remember you're not to fault. Maybe try doing some meditation - there are lots of good free resources online of which I'd recommend the YouTube channel of an Australian yoga teacher Bettina Rae, you might find e.g. her meditation for healing helpful. I'm sending you a big hug!


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