A teen with cancer froze his sperm in the 90s. But now it's vanished

A man who froze a sperm sample when diagnosed with cancer as a teenager only learnt it had been lost when he and his partner went to start IVF decades later – when he had no sperm left.

In a report published on Monday, Deputy Health and Disability Commissioner Dr Vanessa Caldwell found Fertility Associates – the country's largest fertility services provider – breached the patients’ rights code for failing to provide services with reasonable care and skill in the case.

The man (Mr A) had a sample of his sperm placed in storage in 1995, prior to undergoing chemotherapy – the storage was later purchased by Fertility Associates.

Fertility Associates has 22 clinics across Aotearoa and provides IVF, donor/surrogate fertility procedures and cryopreservation of eggs and sperm; fertilised embryos and human tissue (such as ovarian or testicular tissue).

READ MORE: * The Gift of Life: Egg donor becomes surrogate as pay back for sperm donation * Fertility clinic ordered to apologise for disposing of woman's frozen embryos * Cancer patient outraged to discover he can only donate sperm to female partner

Sperm samples are stored in thin plastic straws sealed at each end and placed in a plastic container called a "goblet". Between 20 and 30 goblets are then stored in a cylindrical metal canister. Canisters are stored in a "bank", filled with liquid nitrogen.

Mr A's sample was split between 15 straws, stored within the same goblet.

While sperm can be stored indefinitely in liquid nitrogen, New Zealand's Human Assisted Reproduction Technology Act (2004) imposes a 10-year storage limit.

Anything longer requires a special application – which Mr A had been granted.

In April 2018, Mr A (then in his 40s) and partner, Ms A, began the IVF process; with the intention of using his stored sperm.

On May 25, 2018, after completing her first IVF cycle, Ms A underwent a procedure to retrieve her eggs.

The next step was for Mr A's sperm samples to be retrieved from storage, so they could be thawed and used to fertilise Ms A's eggs.

But the clinic was "unable to locate his samples".

Over the next week (between May 25 and June 2​), a full search was completed of all banks in the clinic – confirming the samples were "no longer in storage".

On June 2, Fertility Associates advised Mr A that the clinic had lost his sperm samples, and outlined his options: including using donor sperm with Ms A's eggs, or undergoing a testicular biopsy to check whether he had any remaining viable sperm.

The couple declined using donor sperm. A biopsy in October did not find any sperm that could be used.

Fertility Associates’ internal investigation found the last time Mr A's sperm samples were known to be in its possession was seven years prior, in 2011.

After considering potential reasons for the loss, it concluded the samples were most likely lost because staff did not follow policy and undertake an inventory check when the storage bank holding the samples was decommissioned.

Caldwell found insufficient information to make a conclusion about the most likely cause of the sample loss.

She acknowledged that Fertility Associates’ policies "may have been appropriate, but pinpointed shortcomings in record-keeping and audit systems that could have assisted identification of how the samples were lost".

Caldwell noted that Fertility Associates was unable to identify which staff were involved, what steps were in place to ensure that they had the necessary skills and training and how the policy was monitored.

"Although a rare event, this was substandard care with a devastating outcome for Mr A and Ms A" – which was exacerbated by Fertility Associates’ "inability to identify exactly how or when the error occurred", she said.

"Fertility Associates has a responsibility to ensure the safe storage of samples in its possession and to have robust systems in place to prevent loss occurring."

Since the complaint, Fertility Associates had apologised to the man and his partner.

The report also noted Fertility Associates engaged in a "restorative process and financial settlement" with Mr A "in efforts to redress his loss"; and made changes to its policies and processes in response.

These included splitting patient samples for fertility preservation between multiple locations in certain circumstances; introducing a new policy that requirements documents relating to the retirement of a bank to be kept for seven years; and changing its policies to require an incident report be raised when any sample is not in the location recorded, among others.