A fertility clinic has lost the sperm of a man who used its storage facility before undergoing chemotherapy.
The man proactively put his sperm into a storage facility before undergoing chemotherapy so he could later conceive a child.
However when he went back to the facility some years later, the company, since bought by Fertility Associates, could not find the sample.
A biopsy has found the man has no more sperm that can be used for conception.
The Health and Disability Commissioner has since criticised the company for its lack of care.
An investigation into the incident and found the storage facility had the sample seven years prior.
Fertility Associates explained the loss happened when the bank holding the sample was decommissioned.
It said staff failed to follow procedure during an inventory check.
However, deputy Health and Disability Commissioner Dr Vanessa Caldwell found that due to poor record keeping there was not enough information to explain the mistake.
"I acknowledge that loss of samples is a rare and devastating risk to assisted reproductive technologies, however I am critical that Fertility Associates lost the man's sperm samples, and that its systems were unable to provide evidence of how or when the loss occurred," Caldwell said.
The company has a responsibility to have robust systems to keep samples safe, she said.
Fertility Associates has since undertaken a number of actions.
It has apologised to the man and his partner and changed some of its policies to require incident reports when samples were misplaced.
Caldwell suggests the company also has its systems reviewed by a field expert and that it implements designated banks for samples over 10 years old.