If ever there was an area of medical practice that should get things right 100% of the time IVF Service Providers would have to be right up there – not that I am encouraging mistakes elsewhere!
The following reveals perfection is a pretty high bar to reach!
‘Weird and icky feeling’: Anxiety for parents after Monash IVF embryo bungles
Two embryo mix-ups by Monash IVF have shaken confidence in the assisted reproductive technology sector. What does it mean for the future of IVF?
5:00AMJune 13, 2025
Radio host Jase Hawkins may have summed up the feelings of many parents or prospective parents this week when he spoke about the latest embryo mix-up by leading fertility clinic Monash IVF, its second reported bungle in the past two months.
After telling listeners he and his partner had conceived their youngest child, Archie, with the help of Monash IVF, Hawkins opened up about hearing news of the error.
“As someone who’s gone through it (IVF), like, it was such a personal experience,” he told his audience on Nova 100 FM. “And whatever company you go through … there’s that trust you have. And yesterday was just that weird, just that icky feeling in your guts.”
Putting yourself in the hands of a fertility clinic to help have a child is a big step, likely born of previous disappointment and heartache. Hope, faith, trepidation, anxiety, daring to dream.
And then the process itself can be gruelling. Injections to stimulate ovaries to help the production of eggs. Egg retrieval. Sperm samples. It’s hard to imagine a health service more intimate.
“In reproductive care, trust is everything,” University of South Australia bioethicist Hilary Bowman-Smart says. “Patients entrust clinics with embryos that may represent their only opportunity to have children.
“This (latest) mix-up – the second reported incident at Monash IVF – risks shaking confidence, not just in one provider but across the entire fertility sector.”
So what exactly has happened?
On Tuesday morning Monash IVF, a listed company and one of Australia’s biggest fertility operators, informed the Australian Securities Exchange it had implanted the wrong embryo in a patient.
The statement said the company had mistakenly transplanted the patient’s own biological embryo back to her, rather than her carrying her partner’s embryo, which was what the couple had requested in their treatment plan. The error occurred on June 5 at a clinic in Clayton in Melbourne’s southeast.
Inquirer understands that it should have been picked up through an electronic checking process but wasn’t due to the two women having the same surname. It is understood the electronic process was designed for heterosexual couples.
The distressing error compounded another heartbreaking mistake Monash was forced to make public just two months ago, where a woman in Brisbane had carried and then given birth to a child conceived through IVF before learning she had been mistakenly implanted with another couple’s embryo.
The tragic mix-up was uncovered when the birth parents requested the transfer of their remaining frozen embryos to another assisted reproductive therapy provider and the clinic found there were more than there should have been.
It is understood the baby was conceived in 2023 and the parents were informed of the mistake in February this year, meaning they had cared for the baby for several months. Monash IVF didn’t report the matter to the ASX until it became public through the press in April.
Both sets of parents are understood to be devastated about this botched transplant.
The baby’s future has not been made public. But under family law provisions it is the birth parents who are considered the legal parents of the baby, meaning the biological parents have no legal claim. Whether that is the situation that has played out in this case is not known.
Monash IVF has apologised to the affected families in both incidents and has included the latest Melbourne issue in the scope of an independent review already being conducted into the Brisbane matter. After the first incident it described the mix-up as an isolated incident and the result of “human error”.
But that has not been enough for the company’s shareholders or its board. The two embryo mix-ups come after a mishandled genetic testing program that led to Monash IVF last year paying $56m to settle a class action brought on behalf of more than 700 people. The program was suspended in 2020 after it was discovered that faulty results might have meant healthy embryos were unnecessarily discarded.
The company’s share price sat at $1.42 in August 2024, dropped from $1.08 to 67c on the day the first embryo bungle was reported, and dropped again from 75c to 55c after the second mix-up was declared.
On Thursday the company notified the ASX in a brief statement that the board had accepted the resignation of its chief executive, Michael Knaap, effective immediately. He had been in the role since 2019.
“Since his appointment in 2019 Michael has led the organisation through a period of significant growth and transformation, and we thank him for his years of dedicated service,” the statement said.
That may well not be the end of the matter, as governments are not happy either. State and federal health ministers urgently included the regulation of the assisted reproductive technology sector on the agenda of their meeting on Friday and the Victorian government has ordered its own investigation.
“These cases are just shocking, deeply distressing, and undermine confidence in the system,” federal Health Minister Mark Butler told ABC radio on Thursday.
“As governments, we’ve got a responsibility to see whether there are better levels of regulation that should be put in place and to inject some confidence back into a system that delivers such joy to so many thousands of families every year.”
Victorian Health Minister Mary-Anne Thomas said families should be confident they were receiving the highest standard of fertility treatment and “it is clear Monash IVF has failed to deliver that, which is completely unacceptable”.
Thomas said Victoria’s Health Regulator would be conducting its own investigation into the latest incident.
The ministers’ discussion will focus on whether IVF, currently subject to nationally consistent clinical standards but regulated through state and territory laws, should be moved to a nationally consistent federal framework.
Government and company investigations are one thing, human responses another. The fertility community is large. There were around 100,000 IVF cycles carried out in Australia in the past year alone. It includes prospective users thinking about their options, patients with embryos awaiting transplant and parents with children born through IVF who put their faith in the system. And it includes the many medical, technical and nursing staff in the industry.
The experts will point to how incredibly rare events such as this have been across the four decades of assisted reproductive technology helping people become parents. That is true. And they will talk about the Australian system being extremely robust on international comparisons.
But people are people. And two incidents reported within two months of each other, both at the same company, will have anxiety levels rising.
“The reaction was very quick and very strong from both my clients and also my followers on Instagram, just: ‘Oh my gosh, how does this happen again?’ ” former clinical embryologist and IVF patient advocate Lucy Lines told the ABC.
“(It ranged) from people who’ve completed their families with IVF, who are at home with their children and now feel anxious about whether they need to do DNA testing, through to people who are currently having treatment, maybe they just had a transfer or they’re about to have a transfer, feeling very anxious about that.
“I’m not trying to be dramatic but I’m like, I don’t trust (our frozen embryos) sitting in that freezer at the moment … It just made me think last night, well, I think we need to speed up that conversation about what we want to do with them because at the moment I don’t trust the current situation”
“And even people who are looking down the barrel of doing IVF, already feeling anxious about it as it is, and now that anxiety has been ramped up a whole lot of levels.”
Hawkins says his trust has been shaken. “I’m not trying to be dramatic but I’m like, I don’t trust (our frozen embryos) sitting in that freezer at the moment … It just made me think last night, well, I think we need to speed up that conversation about what we want to do with them because at the moment I don’t trust the current situation.”
Swinburne University of Technology senior lecturer of health promotion Evie Kendal also raises the issue of trust in the current system.
“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,” Kendal says.
“Previous safeguards are clearly not up to the challenge of protecting clients against such incidents, and urgent ethical and policy guidance is needed to prevent such mistakes from occurring again.”
Consultant obstetrician Alex Polyakov says it is important to remember that IVF clinics in Australia “operate within some of the most highly regulated and scrutinised environments in medicine”.
“Australia’s assisted reproductive sector is internationally recognised for its rigorous oversight and quality control,” Polyakov says.
“In over 40 years of IVF practice in Australia, these events remain statistical outliers – still extraordinarily uncommon. However, their emotional and ethical implications are significant, and concern among patients is entirely understandable.”
Practitioners are battling privately with ethical and practice challenges in the wake of these errors.
Inquirer understands that questions have been raised about whether the obligations of Monash IVF, a listed company, to notify the ASX of events that may affect its share price have overridden the ethical obligation of a doctor to provide appropriate care and welfare of their patient, including confidentiality where necessary.
While the families involved in these incidents have not been named publicly, seeing the matter raised in the public domain in any event would be emotionally difficult, medical practitioners say.
Monash IVF was criticised in April for not reporting the Brisbane incident to the ASX in a timely manner and was much quicker to report the latest Melbourne error.
A further conundrum for specialists in this field is whether they should now include the remote possibility of an embryo mix-up as part of their informed consent process.
Monash IVF’s embryo mix-ups clearly have dented trust across the assisted reproductive technology sector, and in such an emotionally charged area winning it back will be hard. It is vital that work is done. The hopes and dreams of so many families depend on it.
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We all know being 100% error free is a very high bar, to say the least, but avoiding errors must be pretty much certain or the industry will loose its social license!
This just means that both the systems and the people involved have to try really hard and get the error rates as close to zero as possible, and all the supportive tricks needed to make systems reliable need to be implemented and monitored.
To achieve this all the techniques of error prevention need to be brought into play and vigorously applied with everyone understanding the responsibility they carry! A tall ask but the best we can do, being human! Careful study of airline systems would be a good place to start!
David.
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