Table 2

Study flow table

Summary of working group improvement efforts by phase of implementation
Interventions by working groups
PhaseDate completedLaboratory teamClinical team
11 Jan 2020ICSI procedure changes:
  • PVP added <10 min before ICSI.

  • Sperm struck only once to immobilise.

  • Egg manipulation on holding pipette reduced.

  • Eggs injected straight after denudation.

  • Strict ICSI HCG injection times 40–41 hours.

  • ICSI Rig use and micromanipulation needles standardised.

  • Handling media used for egg collections and denuding (trial use of handling media for ICSI dishes for example, split cases).

  • Washing step when eggs placed within culture dishes after egg collection (wash off handling media),

  • Use of ovens (switch off incubator gas),

  • Efficiencies with old equipment (until replacement available) heated table used for egg collections,

  • Strict fertilisation check times; 16 HPI ICSI, 16–18 HPI IVF.

  • Max eggs per dish; 3 eggs per ICSI dish, 5 eggs per denuding dish.


5S within lab: remove all paper and declutter as much as possible.
  • Increase progesterone (double dose).

  • Strict individualised HCG trigger times for each patient to ensure egg collection times at 36 hours for IVF and 37 hours for ICSI cases.

  • Nurses to call patients after scan to give times following review with lab team once final list and order is established.

  • First egg collection to not start before 36 hours post HCG trigger, no longer an ICSI case due to requirement to check fertilisation at 16 HPI the following day.

  • Reduced follicular flushing at egg collection.

COVID-19 pandemic—nationwide fertility sector closure, fresh cycles stopped from 27 March 2020 until 14 August 2020.
Forced change to procedures; only one theatre list provided to fertility due to pressure on the NHS, egg collections only on Fridays going forward, IVF centres required to have a recommencement strategy in place to apply to reopen this included how patients would be prioritised once treatments restarted, for example, who was offered treatment first on the waiting list, those cancelled in March/April, advanced maternal age, funding criteria/expiration.
226 Feb 2020
14 Aug 2020
8 Oct 2020
New equipment installed, validated and implemented.
Unica enclosed hood for egg collections (heated table decommissioned)
RI heated stages × 3
 New Cook suction pump used (replaced old unserviceable equipment)
310 March 2021Implement change to ICSI injections procedure: ICSI dishes made using handling media (MHM-C)
  • HPI, hours postinjection; ICSI, intracytoplasmic sperm injection; IVF, in vitro fertilisation; RI, Research Instruments.