By Grant McArthur
Monash IVF is facing an expanded investigation over a “completely unacceptable” second embryo mix-up revelation in just two months.
In the latest Monash IVF bungle, a Melbourne woman had her own embryo mistakenly transferred to her, during a procedure in which she was supposed to receive an embryo from her partner.
It is the second Monash IVF bungle admitted to this year.Credit: Istock
The Melbourne embryo mix-up occurred last Thursday, just two months after Monash IVF was forced to admit that an error at its Brisbane clinic resulted in a Queensland woman giving birth to a stranger’s baby.
At least one IVF expert says it is likely other embryo mix-ups have occurred in Australia previously, though the lack of reporting requirements and the scant detail that regulators release means the public may never know.
IVF doctors have also told The Age that unless there is greater transparency over such incidents, the opportunity for fertility clinics to avoid further issues may be lost.
In a statement to the ASX on Tuesday, Monash IVF revealed it had mistakenly transferred the wrong embryo to a woman at its Clayton clinic.
“Monash IVF has extended its sincere apologies to the affected couple, and we continue to support them,” the statement said.
“Monash IVF is conducting an internal investigation into the incident. It has also extended the scope of the independent review being conducted by Fiona McLeod AO, SC, in relation to the Brisbane incident, noting that the different incidents occurred some years apart.”
The fertility giant confirmed it was now stepping up safeguards for its patients, including additional verification processes and electronic witness systems, but said there were instances “whereby manual witnessing is required”.
The Melbourne mix-up comes just six weeks after Victoria’s Health Regulator renewed the licence of several Monash IVF centres, including its Clayton clinic.
Health Minister Health Mary-Anne Thomas slammed Monash IVF and said it was required to fully co-operate with an investigation from the regulator.
Health Minister Mary-Anne Thomas said the Health Regulator had been notified about a Monash IVF embryo bungle on Tuesday morning.Credit: Simon Schluter
“Families should have confidence that the treatment they are receiving is done to the highest standard,” Thomas said.
“It is clear Monash IVF has failed in delivering that – which is completely unacceptable.”
Last year, Monash IVF paid $56 million in compensation to settle a class action involving 700 families over a bungled genetic test, which may have cost dozens of families the chance to have children.
President of the Fertility Society of Australia and New Zealand Dr Petra Wale moved to reassure the public that Australia’s assisted reproductive technology (ART) systems were among the “safest, most transparent, and tightly regulated in the world”.
“Although the embryo transferred was the patient’s own, we acknowledge the emotional toll this has taken and extend our heartfelt sympathies to those involved,” Wale said.
“While these incidents are deeply difficult for those affected, they are exceedingly rare and must be taken seriously, without losing sight of the overwhelming positive contributions made by the sector.”
Victoria’s 24 licensed ART clinics are required to report all adverse events to Victoria’s Health Regulator. But while it details the number of adverse events relating to “clinical” errors, the regulator does not provide additional details, such as whether incorrect embryos have been transferred.
IVF pioneer Professor Gab Kovacs, who was the medical director of Monash IVF before retiring more than a decade ago, said the sheer number of ART procedures taking place made it likely that mix-ups would occur on rare occasions, and it was unlucky that Monash IVF had been involved twice in such a short period.
“It is human error and it will happen again, it’s just because Monash IVF is a public company that any adverse incident has to be reported to the exchange, so they become public,” Kovacs said.
“Probably, there are other mix-ups at other clinics that we don’t know about.
“It is sad news for everybody, for the patients involved, for the staff who made the mistake, and for the company.
“It is impossible to avoid human error. Unfortunately, while there are humans working things will go wrong.”
University of Melbourne Associate Professor Alex Polyakov, who is also the medical director at Genea Fertility Melbourne, said greater transparency was required to limit the chances of errors reoccurring.
“If an incident like this comes into [the] public domain for whatever reason, it would be important for the regulator to provide information to clinics as to the specifics of the incident,” he said.
“We need to know why it happened, how it happened, and how to prevent it from happening in the future. I think that’s the role of the regulator.”
No.1 Fertility owner and medical director Dr Lynn Burmeister said the latest incident required deeper examination.
“Patients trust that when they are with a clinic, there are watertight procedures in place to protect them,” she said.
“With more than one such incident now identified, it is time for an independent review into how this could have occurred.”
Monash IVF’s share price began trading on Tuesday at 74 cents, but dropped to 54 cents following disclosure of the Clayton embryo error.
It continues a dramatic decline for Monash IVF investors, who saw the value of their shares plunge from $1.08 to 69 cents when news of its Brisbane embryo mix-up became public on April 11.
The group’s shares traded at $1.42 in August last year.
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