Standards › Standard 8 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FRT-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 8.4
At a glance
- Gametes and embryos are stored in monitored conditions with alarms.
- Each alarm is answered within the set time, and the response is recorded.
- A back-up storage system is ready and tested.
- A storage failure triggers the written response at once.
- Stop and get help straight away if: an alarm is not answered, or a storage failure happens with no back-up in place.
1. Purpose
To protect each gamete and embryo from a storage failure (8.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A storage failure can destroy years of work. Monitored storage with alarms, a defined response and a back-up is the only protection against a silent failure.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Senior embryologist | Owns the storage, alarms and back-up | Embryologist |
| Duty embryologist | Answers alarms and records the response | Embryologist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Monitor.
- Keep storage monitored at all times, with alarms set to the approved limits (FRT-REG-002).
Key point: Alarms on at all times.
Step 2. Respond.
- Answer each alarm within the set time, follow the failure response, and record it.
Key point: The response is written.
Step 3. Back-up.
- Test the back-up storage on the schedule and record the test.
Key point: A back-up that is not tested is not a back-up.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Alarms answered within the set time | 100% | Monthly | Senior embryologist | Escalate to chief executive |
| Back-up storage tests on schedule | 100% | Quarterly | Senior embryologist | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| FRT-REG-002 | Storage monitoring and alarm log | Log |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ESHRE revised guidelines for good practice in IVF laboratories (2015). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Equipment, calibration, maintenance and environment (L-05)
- Information security, LIS downtime, backup and data protection (L-10)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)