Failure mode and effects analysis of witnessing protocols for ensuring traceability during PGD/PGS cycles  Danilo Cimadomo, Filippo Maria Ubaldi, Antonio Capalbo, Roberta Maggiulli, Catello Scarica, Stefania Romano, Cristina Poggiana, Daniela Zuccarello, Adriano Giancani, Alberto Vaiarelli, Laura Rienzi  Reproductive BioMedicine Online  Volume 33, Issue 3, Pages 360-369 (September 2016) DOI: 10.1016/j.rbmo.2016.06.002 Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 1 Design and timeline of the study. qPCR-based blastocyst stage PGD/PGS was introduced in April 2013. A FMEA was performed in September 2014 through which we defined critical procedures and related failure modes. Corrective measures were then arranged and prospectively evaluated between September 2014 and April 2015. PGD/PGS = preimplantation genetic diagnosis and aneuploidy testing; FMEA = Failure Mode and Effects Analysis. Reproductive BioMedicine Online 2016 33, 360-369DOI: (10.1016/j.rbmo.2016.06.002) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 2 qPCR-based blastocyst stage PGD/PGS cycle workflow. The whole procedure is based on 5 phases: (1) blastocyst biopsy; (2) biopsy tubing; (3) blastocyst cryopreservation; (4) diagnosis; and (5) blastocyst warming. The operators and witnesses involved are embryologists (light and dark green), molecular biologists (light and dark pink), and a geneticist (yellow). Each step is represented by a box. Bicolour boxes represent a witnessed step. The black screen icons on the top right angle of some boxes, identify the use of a camera-equipped microscope in turn connected to a screen within the hood (first corrective measure). The dark green triangle in the “final check” tricolour box represents the third independent check of the medical report by an embryologist before approval (second corrective measure). The black medical report icon on the top right angle of “unaffected/euploid blastocyst warming” and “warming of the blastocyst to be re-biopsied” boxes symbolizes the instruction to the witness to print out the medical reports from all PGD/PGS cycles undertaken by the couple. Only after paying particular attention to the correspondence between diagnosis and cycle ID, warming can be officially authorized by signing a checklist (third corrective measure). In the case of an inconclusive diagnosis (follow the red arrows), the blastocyst to be re-biopsied is warmed and the whole workflow is followed again from the beginning as for any other blastocyst. The only difference consists in the further caption “re-biopsy” labelled on the PCR tube for tubing and in all the paper-based and electronic reports. PGD/PGS = preimplantation genetic diagnosis and aneuploidy testing. Reproductive BioMedicine Online 2016 33, 360-369DOI: (10.1016/j.rbmo.2016.06.002) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 3 Biopsy tubing step after the implementation of the corrective measure entailing the use of camera-equipped microscope connected to a screen within the hood. (A) EWS monitor displaying patient and cycle records, couple and cycle IDs; (B) tagged biopsy dish; (C) camera-equipped microscope connected to a screen within the hood; (D) screen displaying the drops containing the biopsied fragment and identified by marked embryo IDs; (E) metal sterile cool rack carrying the tubes identified by centre, couple, embryo and cycle IDs, where trophectoderm fragments will be moved. EWS = electronic witnessing system. Reproductive BioMedicine Online 2016 33, 360-369DOI: (10.1016/j.rbmo.2016.06.002) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions