‘Unacceptable': Horror IVF incident
Fertility treatment company Monash IVF has admitted to a second IVF mistake, again putting the wrong embryo into a patient.
The latest incident happened on June 5 at the company's Clayton clinic in Melbourne's southeast.
'A 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 said in a statement to the ASX on Tuesday.
'Monash IVF is conducting an internal investigation into the incident.
'Monash IVF has extended its sincere apologies to the affected couple, and we continue to support them,' the statement reads.
Victorian Health Minister Mary-Anne Thomas said Monash IVF's failure was 'completely unacceptable' and families should have confidence that the treatment they received was done to the highest standard.
'The Victorian Health Regulator was alerted to this incident this morning and is now investigating Monash IVF and this incident,' Ms Thomas said.
'Monash IVF are required to co-operate fully with this investigation and provide clear answers on how this happened.'
The Victorian Health Regulator was notified on Tuesday morning of the incident.
In 2023, Monash IVF staff in Brisbane mistakenly implanted the wrong embryo into another woman; the recipient of the embryo gave birth to the child.
Monash IVF reported this incident to authorities and the news of the mistake became public
in April this year.
Victorian barrister Fiona McLeod is running an independent review into the Brisbane incident. Ms McLeod's investigation is being widened, Tuesday's announcement said.
'(Monash IVF) has also extended the scope of the independent review … noting that the different incidents occurred some years apart. Monash IVF will provide an update on the findings of the expanded review in due course,' the statement reads.
The company said checks and balances were also being improved 'commencing immediately'.
'Monash IVF will implement interim additional verification processes and patient confirmation safeguards over and above normal practice and electronic witness systems, to ensure patients and clinicians have every confidence in its process,' the statement read.
'Whilst industry leading electronic witness systems have and are being rolled out across Monash IVF, there remains instances and circumstances whereby manual witnessing is required.'
Monash IVF alerted the regulators to the incident, the company said.
Swinburne bioethics expert Evie Kendal said another woman receiving the wrong embryo would cause concern among reproductive services patients in Australia and overseas.
'Many of us feel immediate sympathy for the individuals involved and the complicated feelings this incident may have caused,' Dr Kendal said.
'The case also opens up discussions of different definitions of kinship, including the genetic, gestational and social elements of motherhood that advances in reproductive technologies have separated into distinct components.
'By introducing more areas of human intervention into reproduction, such technologies also introduce the potential for human error, as has been seen in these cases.'
Previous safeguards were clearly not up to the challenge of protecting clients against such incidents, Dr Kendal said, adding that urgent ethical and policy guidance was needed to prevent repeat mistakes.
'As new technologies further expand and challenge our conception of the family, we need to stay focused on providing the circumstances for all children to be loved and cared for in society, including when things don't go to plan when using assisted reproduction.'
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One of Australia's top IVF providers mistakenly implanted a patient with her own embryo instead of her partner's. Monash IVF said the incident occurred on June 5 at a clinic in Melbourne but did not provide further details, such as how it learned of the bungle or what the couple planned to do next. The company said it was supporting the couple, who it did not identify. It marks the second fertility clinic mix-up of its kind in the country, heightening concerns about an industry that did not have much active government oversight until recently. The clinic said the patient's embryo was mistakenly implanted under a treatment plan which called for an embryo from the patient's partner to be transferred. The incident builds on a reputational maelstrom for Monash IVF, which was already reeling from an April disclosure that an Australian woman had given birth to a stranger's baby after a fertility doctor accidentally implanted the wrong embryo in Brisbane in 2023. That mix-up sparked concerns about security protocols at IVF clinics and an industry which is only now in the process of being more regulated. Monash claimed the world's first IVF pregnancy five decades ago and is Australia's second-largest IVF provider, carrying out nearly a quarter of the country's 100,000 assisted reproductive cycles a year, according to industry data. "This mix-up, the second reported incident at Monash IVF, risks shaking confidence not just in one provider but across the entire fertility sector," said Hilary Bowman-Smart, a researcher and bioethicist at the University of South Australia. Shares of Monash IVF were down 25 per cent by mid-session on Tuesday, against a rising broader market. The stock is just over half its value before the April announcement. "We had thought the Brisbane clinic embryo transfer error was an isolated incident," Craig Wong-Pan, an analyst at RBC Capital Markets, said in a client note. "We believe there is now risk of a greater impact of reputational damage and market share losses to MVF's operations." Monash IVF had already hired a lawyer to run an independent investigation after the Brisbane incident, and said on Tuesday it has extended the scope of that investigation. It added that it was installing interim extra verification safeguards to ensure patient confidence. It said it had reported the Melbourne incident to the Victorian Department of Health and industry licensing body, the Reproductive Technology Accreditation Committee (RTAC), part of industry group the Fertility Society of Australia. Victorian health minister Mary-Anne Thomas said the department was investigating the company and the incident. "Families should have confidence that the treatment they are receiving is done to the highest standard," she said. "It is clear Monash IVF has failed to deliver that, which is completely unacceptable." Fertility Society president Petra Wale said the incident would have had an emotional toll on the family, but stressed mistakes in the sector were rare. The society reiterated a call to implement nationally consistent laws around IVF. Currently, the country's IVF industry is regulated by a combination of industry bodies and state and territory health departments, resulting in a governance and compliance system that some groups say is too complex. Reports of transferring the wrong embryo are rare, according to fertility experts, and Monash's Brisbane mix-up was widely reported as the first known case of its kind.
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