Human error allegedly to blame for compromised eggs and embryos, tank supplier says

University Hospitals said it is still investigating.

April 10, 2018, 10:00 PM

An Ohio fertility clinic that lost thousands of eggs and embryos due to what it said was a storage tank glitch may have been too quick to blame the machine, according to the tank supplier.

Custom Biogenic Systems (CBS), the company that supplied the storage tank to University Hospitals of Cleveland, said in a statement that an initial review it conducted has found that "our equipment did not malfunction" during the weekend of March 3 to March 4, when more than 4,000 eggs and embryo assets were compromised.

Rather CBS said that human error likely led to the temperature rise that led to the loss of the eggs and embryos.

"The early stages of our investigation into this unfortunate incident indicate it was the result of human error," the CBS statement reads, claiming that the fertility clinic at University Hospitals did not follow what it says were the company's detailed instructions.

Specifically, CBS states that its tanks should not be filled manually with liquid nitrogen as it says University Hospitals may have done.

In a letter to its patients that was sent out in conjunction with Zenty's apology to the clinic's clients posted on the hospital's social media accounts, Zenty said employees were manually filling the tank.

Zenty also said in the letter that the remote alarm system on the tank, which meant to keep tabs of any kind of "temperature swings," was mysteriously off.

"We don't know when the remote alarm was turned off, but it remained off through that weekend, so an alert wasn't sent to our employee as the tank temperature began to rise on Saturday night, when the lab wasn't staffed," he wrote.

Zenty admitted there was some potential that someone turned the alert system off, but said in the letter that "we are still seeking those answers."

Still, the letter suggested the tank "needed preventative maintenance" because the function that automatically adds liquid nitrogen to the tank to keep the specimens frozen had been experiencing difficulties for several weeks prior to the tank's failure.

As a result, Zenty states in the letter, University Hospitals employees were manually filling the tank because of the issues with the autofill function, but the levels of nitrogen that "were monitored and appeared to be appropriate on Friday and Saturday" likely were insufficient.

In its statement, CBS provided an instructional video to show how it says the tank was improperly handled.

In the video, a big thumbs-down icon appears to frown on using the tank to store specimens in liquid nitrogen. Three thumbs-up icons conversely pop up when, according to the company, the tank is used appropriately with a technique called isothermal, which stabilizes temperatures and limits any cross-contamination.

In response, University Hospitals said in a statement that it is still investigating "the ultimate cause of the failure.... But we still have not gotten to the ultimate cause."

"We intend to continue to work with the tank manufacturer to ensure this does not happen again," the statement reads. "We’ve been careful to not assign blame. But we’ve accepted responsibility. We will not comment any further due to pending litigation."

The Cleveland clinic has been hit with a class-action lawsuit, ABC News previously reported.