Fertility Giant Admits Wrong Embryo Implanted in 2nd Error This Year

After the Brisbane case in February, a second embryo mix-up has occurred.

A young family at their home in the Eastern Suburbs in Sydney, Australia, on April 20, 2020. Lisa Maree Williams/Getty Images

Monash IVF has confirmed a second error with an embryo implant, this time at its Clayton laboratory in Victoria, just months after a separate incident in Brisbane involved the wrong embryo being implanted into a person.

The company disclosed the latest issue in a statement to the ASX on June 10, revealing the mishap occurred on June 5.

“The patient’s own embryo was incorrectly transferred to that patient, contrary to the treatment plan which designated the transfer of an embryo of the patient’s partner,” Monash IVF stated.

The provider apologised to the affected couple and said support services are being offered. An internal review is underway, alongside an expansion of the independent investigation initially launched after the Brisbane incident.

Monash IVF also committed to immediately improve its verification systems beyond standard practice.

Despite existing electronic witness systems being progressively introduced, the company acknowledged that some manual procedures remain in place, which may have contributed to the failure.

Insurers have also been notified with the incident to “fall within the scope of its insurance coverage.”

Repeat Failure Raises Concerns

The company came under intense scrutiny earlier this year when it admitted that a woman at its Brisbane clinic was implanted with an embryo that did not belong to her.

That child was later born without any biological link to the mother.

Monash IVF discovered the error in February during a routine request to transfer remaining embryos, where an unexpected extra embryo was located.

“Something has gone seriously wrong, so that suggests a protocol that’s inadequate or a failure to adhere to the protocol,” said Melbourne Law School’s Professor Ian Freckelton KC.

Under current legal standards, the birth mother and her partner are presumed to be the child’s legal parents.

However, the genetic parents might still pursue custody, and compensation claims are a possibility.

The Queensland Health Department noted the Brisbane error predated stricter IVF legislation that came into effect in September 2024. The new laws aim to enhance transparency and accountability in the ART industry

“We will work with Monash IVF to reinforce safeguards in their Queensland clinics and ensure any risks are identified and mitigated,” a spokesperson said.

Federal Health Minister Mark Butler also pledged to raise the issue with his state counterparts.

‘Deeply Triggering’ for IVF Families

The revelations have concerned the IVF community, with Samantha Payne from the Pink Elephants Support Network saying the news is distressing for many.

“There will be people who will be deeply triggered by this and they'll want some reassurance around their own experiences of fertility,” she said.

Around 1 in every 18 babies in Australia is born through IVF, with no other known cases of a similar embryo mix-up reported locally.

However, such incidents have been recorded overseas.

In the United States, Krystena Murray sued a Georgia fertility clinic after giving birth to a child that was not genetically hers. She eventually surrendered the baby after the biological parents initiated legal proceedings.

Empirical bioethicist Hilary Bowman-Smart said that ethical considerations must include the child’s right to know the truth.

“From an ethics perspective, I don’t think we can say it’s a stranger’s baby,” she said. “The birth mother was pregnant for nine months, gave birth, and raised the baby along with her partner for several months.”

Regulatory Gaps Exposed by Legal Experts

Lucinda Gunning, a lawyer with Carroll and O’Dea, noted that these events highlight the lack of consistent national regulation in assisted reproductive technology (ART).

“Unlike some other areas of medical practice, ART exists in a fragmented legal landscape,” she said.

While some jurisdictions have their own legislation, states like Queensland depend heavily on national accreditation from the Reproductive Technology Accreditation Committee (RTAC).

This decentralised oversight results in discrepancies in safety protocols and complaint-handling processes.

Gunning noted that many clinics still rely on manual labelling and verbal confirmations.

“Introducing more robust electronic tracking systems, biometric verification, and mandatory dual-signature checks could significantly reduce the risk of error,” she said.

Transparency remains another area of concern. The Brisbane mix-up came to light only after an internal audit linked to unrelated patient inquiries.

Gunning believes there is a strong case for mandatory reporting of critical incidents to both patients and regulatory authorities.

AAP contributed to this article.