Hepatitis B positive donation stored with negative donations

Record number: 
733
MPHO Type: 
Estimated frequency: 
Never described in human ART setting No case of cross contamination between gametes and embryos during cryopreservation in animals and in humans
Alerting signals, symptoms, evidence of occurrence: 
Sperm. Cryopreservation of sperm (12 straws stored) and use of fresh sperm for ICSI outside a specific viral risk circuit in a patient with Hepatitis B surface antigen positive. The serology hepatitis B was considered as negative due to an error in the reading of the laboratory results. Risk of transmission to patients who had gametes stored in the same container plus patients that had an attempt the same day.
Demonstration of imputability or root cause: 
Discovered during Quality Assurance review
Suggest references: 
AAA