AusHealthIT Poll Number 803 – Results – 20 July 2025.

Here are the results of the recent poll.

Do You Believe Australia Will Ever See Any Of The Promised Nuclear Submarines From The USA?

Yes                                                                     11 (39%)

No                                                                      17 (61%)

I Have No Idea                                                    0 (%)

Total No. Of Votes: 28

A very clear vote – with little hope for subs!

Any insights on the poll are welcome, as a comment, as usual!

Not bad voter turnout – question must have been decent. 

0 of 28 who answered the poll admitted to not being sure about the answer to the question!

Again, many, many thanks to all those who voted! 

David.

It Makes Good Sense To Give Wild Bats A Very Wide Birth Indeed

This appeared last week:

A man has died from Australian bat lyssavirus. Here’s what you should know

By Bronte Gossling

July 4, 2025 — 1.59pm

Key points

• A NSW man in his 50s died this week from Australian bat lyssavirus
• It’s the fourth confirmed case of Australian bat lyssavirus in the country, and the first in NSW
• Australian bat lyssavirus, identified in 1996, is closely related to rabies, though they are not identical
• Once symptoms of Australian bat lyssavirus present in humans, there is “no effective treatment”, authorities say

The first reported case in NSW of Australian bat lyssavirus – a rare disease closely related to the notorious rabies – resulted in the death of a man in his 50s this week, several months after his exposure to the infection.

It’s the fourth confirmed case in Australia since 1996, and all have been fatal. But what is Australian bat lyssavirus, and should Australians be worried? Here’s what to know.

What is lyssavirus?

Lyssaviruses are a group of RNA viruses that are transmitted to humans with a bite or a scratch from an infected animal. Australian bat lyssavirus falls under this umbrella, as does the deadly virus rabies, which is not identical to Australian bat lyssavirus though they are closely related.

Currently, rabies does not occur in land-living animals in Australia. Australian bat lyssavirus, however, does occur in Australia and is transmitted to humans from bats. Like rabies, which is one of the most notorious and hard-to-treat diseases humans can catch from animals, once symptoms develop, Australian bat lyssavirus is fatal.

Four cases of Australian bat lyssavirus infections in humans have been recorded since the virus was identified in 1996. Three of those cases were in Queensland, the most recent being in 2013 when an eight-year-old boy died after being bitten by an infected bat while holidaying in the Whitsundays. The first confirmed case in NSW resulted in the death of a man in his 50s this week.

How common is lyssavirus in bats?

According to a 2018 article from the Australian Journal of General Practice, it’s estimated that Australian bat lyssavirus is prevalent in less than 1 per cent of healthy bats. In sick, injured or orphaned bats, that prevalence rate is estimated to be between 5 and 10 per cent. Overall, there’s a total population prevalence estimate of less than 0.5 per cent, per another 2018 study.

Between January and June 2021, Wildlife Health Australia reported 27 cases of Australian bat lyssavirus in bats across Australia, with 14 occurring in Queensland, nine in NSW and two each in South Australia and Victoria. At June 2023, according to Wildlife Health Australia, there were 407 reported cases of Australian bat lyssavirus in bats across Australia over 28 years, since 1995.

Keira Glasgow, a director in health protection at NSW Health, said on Wednesday that people should assume any bat in Australia could be carrying Australian bat lyssavirus. That includes flying foxes, other fruit bats and insect-eating microbats.

How can Australian bat lyssavirus be passed on to humans?

Like rabies, a bite or a scratch from an infected bat is how Australian bat lyssavirus is transmitted to humans. It can also be transmitted by other exposure through the eyes, nose or mouth to an infected animal’s saliva. It’s for this reason, Glasgow said, only trained and vaccinated wildlife workers should handle bats, and NSW Health advises in general to avoid handling any land-dwelling wild or domestic mammal in countries with a rabies virus risk.

NSW Health advises anyone who sees a bat distressed, injured or trapped on the ground to not try to rescue it. Instead, people should call WIRES’ trained experts on 1300 094 737 or local wildlife groups.

What to do if you’re bitten by a bat:

1. Seek urgent medical assessment
2. Wash the wound thoroughly for 15 minutes with soap and water
3. Apply an antiseptic with antivirus action, such as Betadine, and allow it to dry
4. Patients require treatment with rabies immunoglobulin and rabies vaccine

What does lyssavirus do to humans and what are the symptoms?

Australian bat lyssavirus affects the central nervous system, with early symptoms being described as flu-like, including headaches, fever and fatigue. Eventually, the illness progresses to paralysis, with convulsions and delirium. Death usually comes within a fortnight of symptoms presenting.

According to NSW Health, the previous three human cases of Australian bat lyssavirus had wide variability when it came to their incubation periods, as some took several days and others several years for symptoms to present.

How is it different from the Hendra bat virus?

Hendra is another rare disease that’s passed from an infected horse to humans, with very few reported human cases in Australia. Since 2012, a vaccine for horses has been available.

Hendra virus, believed to be transmitted from flying foxes to horses via contaminated bat urine, droppings or saliva, is not the same as equine flu, which is highly contagious among horses but does not infect humans.

It’s also believed that Hendra virus is not transmitted to humans directly from flying foxes, only through human contact with an infected horse’s bodily fluids. Human-to-human Hendra virus transmission has also not been reported.

Should Australians be worried about lyssavirus?

One fortunate aspect of Australian bat lyssavirus being so closely related to rabies is that rabies prevention measures can effectively protect humans from Australian bat lyssavirus when symptoms are detected early.

“It is incredibly rare for the virus to transmit to humans, but once symptoms of lyssavirus start in people who are scratched or bitten by an infected bat, sadly there is no effective treatment,” Glasgow said. “If you are bitten or scratched by a bat, urgent medical assessment is crucial.”

NSW Health said that in 2024, 118 people required medical assessment after being bitten or scratched by bats. The man who died this week received treatment several months ago after being bitten by a bat. Glasgow said further investigation was under way “to understand whether other exposures or factors played a role in his illness”.

Meanwhile, Dr Alison Peel, a veterinarian and wildlife disease ecologist at the University of Sydney, told this masthead that it’s not the time to panic or “persecute bats”, as they are essential to our ecosystems.

With Angus Thomson

Here is the link:

https://www.smh.com.au/national/nsw/a-man-has-died-from-australian-bat-lyssavirus-here-s-what-you-should-know-20250704-p5mcho.html

The bottom line is to give any wild bats a very wide berth and seek expert medical help promptly if you are bitten. This is a very dangerous virus and needs to be avoided along with its bat host!

David.

It Is Good To See We Are Making Headway With The Apparently Misnamed PCOS.

This appeared last week and I think it is pretty important…..

Australian professor leads bid to change the name for polycystic ovary syndrome

Misdiagnosed, missed entirely, and misunderstood. Polycystic ovary syndrome, or PCOS, needs a name change to remove barriers to care.

Bimini Plesser

13 July, 2025

Polycystic ovary syndrome is so fundamentally misunderstood, patients, researchers and medical professionals the world over are trying to change its name, with the effort led by Australian medical researchers.

Despite its long list of symptoms, including acne, facial hair, weight gain, diabetes, depression, anxiety, and infertility, Monash University academics have found the name PCOS often leaves people thinking it’s primarily a disease of the ovaries. But dangerous ovarian cysts are not a feature of this chronic condition, and the symptoms most women notice have nothing to do with their reproductive system, the researchers say.

Professor Helena Teede, director of the Monash Centre for Health Research Implementation, said little was known about the broader symptoms or causes of PCOS when it was named in 1935.

The focus on ovarian cysts fails to reflect the reproductive, metabolic and endocrine (hormonal) features of the condition, Professor Teede said.

A Monash University-led research paper surveyed thousands of people across five continents in 2015 and 2023 to gauge support for a name change.

Of the 7708 people surveyed, 86 per cent of PCOS patients and 76 per cent of health professionals supported renaming the condition.

Professor Teede is at the forefront of the bid to change the name, a process she describes as “complicated”.

A new survey, which already has more than 5000 responses, is being conducted across the world, in which patients and health professionals vote to define the terms of a new name. Professor Teede said that in the next phase, representatives from about 100 societies and patient groups will meet in a series of international workshops and go through a “very

formal structured process” of voting.

Once the group comes to a consensus, it will endorse the chosen name and begin the dissemination process.

Professor Teede said this decision should be made before the end of 2025. All journals and textbooks that publish anything about PCOS will be made aware of the new name and enter a transition period of five years, during which they’ll refer to the condition using its new name, “formerly known as PCOS”.

The “official sign-off” on the name will come from the World Health Organisation’s International Classification of Diseases, but Professor Teede said this could take a few years.

She said PCOS was an ill-fitting name, as it “does not reflect the broad range of health impacts”, so this change, no matter how complicated, was necessary. “The focus on ovarian cysts, which are not true cysts but rather eggs or follicles that have stopped growing, overlooks the impacts of this multisystem disorder, leading to confusion, missed and delayed diagnosis, and inadequate information provision and care,” Professor Teede said.

Education was “one of the big barriers” to providing effective care and early diagnoses. “This needs to be taught in high school, where adolescent girls are going through those changes in puberty,” she said.

At 21, Bimini Plesser was diagnosed with polycystic ovary syndrome (PCOS), a condition that... more

Professor Teede said PCOS was “taught to be scary women’s business and just about infertility,” when “it should concern everyone”.

“Even in medical training, it’s only educated in obstetrics and gynaecology,” she said. “Dietitians and psychologists … never hear about it, even midwives, and it’s important in pregnancy.”

Suggesting better education could help protect young women, Professor Teede said the physical manifestations of PCOS could also be psychologically damaging.

Women with PCOS were at increased risk of depression, anxiety, obsessive-compulsive disorder and body dysmorphia.

“Accurate and timely diagnosis is critical,” Professor Teede said.

“Without answers for what they’re experiencing … these women can start to believe something is wrong with them.”

“That’s when we start to see those psychological features in full force.”

Those involved in the Monash-led global initiative hope a name change can help to reduce confusion surrounding PCOS, raise awareness for the condition, and lead to earlier, more effective diagnosis and management.

Here is the link:

https://www.theaustralian.com.au/health/medical/australian-professor-leads-bid-to-change-the-name-for-polycystic-ovary-syndrome/news-story/a1b20244fe9ead7d1fb7cf70111242bf

This is a disease with a great deal of associated suffering and specialist care from domain experts can really make a difference to quality and length of life.

More power to the are of all working to help us do better with this awful disease.

David.

I Had Thought We Were A Bit Better Than This Now! Seems Not…..

This appeared very recently:

New hire allegedly sacked one hour after advising of pregnancy

David Marin-Guzman Workplace correspondent

Jul 13, 2025 – 11.48am

A major childcare company has been accused of sacking a new hire just one hour after she advised the business she was pregnant, setting in train a damages claim over unlawful discrimination.

Multinational group Busy Bees, which operates 144 centres in Sydney, Melbourne, Brisbane and Perth, allegedly informed the senior human resources officer “it’s not going to work out” when the woman discovered she was pregnant just days after signing a contract with the company.

The Brisbane woman, who is in her late 30s and is referred to under the pseudonym “Sarah” due to sensitive medical information, says she was forced to plead with her old employer for her job back.

But the Busy Bees manager allegedly gave her a piece of advice: don’t tell your old employer about the pregnancy when asking to return.

Three weeks later, Sarah lost the baby.

She is now preparing to launch a pregnancy discrimination case and breach of contract claim in the Australian Human Rights Commission by the end of this week.

“To have a job offer withdrawn simply because I told them I was pregnant was devastating,” she told The Australian Financial Review.

“What sort of message does this send to the thousands of mothers who place their children in the care of this company because they have to work?

“This is 2025. No professional, or any other female employee, should put up with this. I couldn’t live with myself if I didn’t push back against them.”

Her lawyer, Maurice Blackburn principal Patrick Turner, said the case was particularly striking.

“A company that profits from parenthood shouldn’t be tearing up employment contracts with pregnant employees,” he said.

“Too many women who are the best candidates for the role or for a promotion or for a leadership position are thrown onto the scrap heap once they announce a pregnancy.”

A Busy Bee spokeswoman said “we strongly refute the allegations made and will be defending our position through the legal process in everyway possible”.

“Unfortunately, due to legal proceedings we can’t comment on specifics, but our records present a very different version of events,” she said.

“Our business exists to support families by caring for their children, and we are proud of our record of supporting working parents.”

“While we are unable to comment on the specifics of individual matters, we take all allegations seriously.”

The allegations come as employers now have a positive duty to take reasonable steps to eliminate unlawful sex discrimination in the workplace as part of the government’s Respect@Work reforms.

However, only the Australian Human Rights Commission, not individuals or organisations such as unions, can bring proceedings under the duty and there are no penalties for breaches.

Turner said “employers are clearly not getting the message”.

He said the alleged termination had had a “profound effect” on Sarah’s mental health and they would be seeking significant compensation for distress and humiliation under the Sex Discrimination Act.

According to Sarah, she signed a contract to be Busy Bees’ senior HR business partner in April, just 10 days after responding to a job advertisement and completing successful interviews.

So eager was the company to secure her it urged her to reduce her three-month notice period with her old employer to just one month.

Sarah succeeded in doing so but at the same time realised, to her surprise, that she was pregnant.

When she called to inform Busy Bees that same day, flagging she would need to take six months’ parental leave at the end of the year, she alleges its manager replied the timing was “not ideal” and she would need 24 hours to “mull it over”.

The manager called back an hour later and confirmed she had got advice from “mentors”. She allegedly told Sarah “sorry mate, it’s not going to work out” due to Busy Bees’ acquisition of new childcare sites at the same time as the proposed parental leave.

“I really tried to see how I could make it work, but it just won’t,” the manager allegedly replied, saying that the company would have to readvertise the job.

Sarah’s offers to work hard before her leave to ensure a smooth transition period, take a more junior position in the interim, or recruit a qualified friend to cover for her allegedly went nowhere.

When Sarah said she would have to see if she could get her old job back, the manager replied that she “wouldn’t suggest telling [the employer] about [her] pregnancy but that she had a change of heart”.

Sarah managed to get her old job back. But she says she emailed Busy Bees’ general counsel a couple of days after, outlining what happened and seeking to ensure the company did not discriminate against other women. She says she got no response.

Busy Bees’ spokeswoman said the company had “inclusive recruitment policies and practices that adhere to anti-discrimination laws – including on the basis of pregnancy”.

“We are proud to employ many parents and expecting parents, and we are committed to supporting them at every stage of their journey.”

Here is the link:

https://www.afr.com/work-and-careers/workplace/childcare-hire-allegedly-sacked-one-hour-after-advising-of-pregnancy-20250708-p5mdd2

I suspect there is a HR manager who is going to regret such blatant actions! Really very “naughty” and totally illegal I believe!

David.

It Seems We Are Having Another Moment Of Noticing Adolescence Is A Tricky And Complex Transition!

I do have to say that this is rather a repeating insight – with only the level of complexity and degree of observability changing over time. Growing up is a challenge for all and few slip into adulthood without at least some “disturbance in the Force” ( for the want of a better description ).

The transition from child to adult is a universal experience I reckon, only the level of disruption that results varies as well as how long it lasts!.

Adolescents, it’s time to take back your brains

Yes, you should use your phone. It’s a central part of life. It’s fun, entertaining, central to school and social life. But don’t let it own you.

MATT RICHTEL

5:00AMJuly 12, 2025.

Dear adolescents,

The technology industry wants to own your brain. It wants to suck every second of your life into the machine and spit out money to investors. This doesn’t mean you can’t spend time online and get what you want out of the situation. You just need to be aware of what’s really going on.

Here’s what’s really going on: You are in a bad relationship. With your phone. It’s like a bad romantic relationship where you’re getting the raw end of the deal and you don’t really realise it until after the break-up, months or years later. And you’re like: What the hell? I was totally taken advantage of. I’ll never do that again!

Time to fix the relationship.

I’ll tell you a story of what they say behind your back. Then I’ll tell you why these knuckleheads are so good at taking advantage of you.

Adolescents, it’s time to take back your brains.

Love, Matt.

Your wellbeing is in the hands of industries that want to suck as much time out of you as they can. They’re so good at it. And it’s not because they’re particularly smart. No, they’re just selling something that’s largely irresistible. Dopamine squirts.

I know how good it feels to get squirted.

At the time of the introduction of the iPhone, I noticed a shift in my own behaviour when it came to these devices. I was having trouble putting my phone down. It beckoned to me with magnetic powers. I was particularly curious about my use of the phone when I was driving. I could watch the freaking stupidity in my behaviour as I glanced at my phone while piloting a half-tonne vehicle – an accident waiting to happen.

The trouble is these devices play to your deep neurological wiring and can be so compelling as to be addictive. The games and social media interact with the reward systems in the brain. They provide adults and youths alike with a constant source of stimulation and our craving for social connection, squirts of dopamine from information that is new, scary, bad – all of which play to different primitive impulses.

Imagine that you are a caveperson sitting at a fire and you feel a tap on the shoulder. Could you avoid turning around to look? No, because you wouldn’t know if the tap is friend, foe, enemy, potential mate. When your phone buzzes, it is like a tap on the shoulder from anyone, anywhere in the world.

On top of that, these devices act like slot machines, sometimes paying off for our attention and other times providing less interesting stuff. But, oddly, the science shows, this makes the devices more powerful because you never know which ping is going to be a good one. You must check each time.

The entire business model of companies involved in building the phones and apps is to keep people online as much as possible. They are trying to ensnare our attention and they are amazing at doing it.

This is even more challenging for adolescents. The reason has to do with your brain development. You are wired to explore and, as a result, to have less inhibition. The control centre of your brains are less developed than adults’. So, asking you to ignore the device is asking you to use a part of your brain that isn’t fully developed.

Furthermore, and maybe most importantly, the information you are getting on these devices is social in nature. It is coming from your peers. You could hardly invent a recipe more likely to appeal to an adolescent brain. Bottom line: mobile devices and the social media deliver are a near-perfect delivery system of neurochemicals to the developing brain. This can create some serious problems by hijacking the time of an adolescent, who needs lots of different physical, emotional, and interpersonal experiences for the brain to develop in a healthy way.

Also, your device can be like a drug. Just like a drug, it can distract you and help you escape from what you’re feeling. Is this good? Sometimes, maybe, sure. Is it bad? Also, sometimes. The reason is because how we grow up is partly by learning to live with our real emotions, sensations, experiences, feelings. Escaping those all the time makes it hard to learn how to just exist.

Does this mean you shouldn’t use a phone? No. Meaning: Yes, you should use your phone. It’s a central part of life. It’s fun, entertaining, central to school and social life.

But own that shit. Don’t let the knuckleheads own you. Take time to decompress. Use social media, and all the rest, on your terms.

Here’s one simple way to do it that will give you an even greater sense of reward than you usually get. Put the phone down for 30 minutes, or an hour. Let the messages build up, put off the next level of the game, let the anticipation grow as you do something else. Then, return to the gadget and get extra pleasure from the delayed gratification.

Make that phone your tool, instead of being its tool. Make it your slave, don’t let it enslave you.

Dear parents

It would be really nice, were it true, to be able to say that the rise in mental health distress is a direct result of heavy use of social media. It’s just not that straightforward; there are other factors at play.

Adolescence is, by evolutionary design, a period of risk-taking and diversification. That is true of adolescence across time. But this generation is experiencing a twist.

For centuries, adolescents were not looking so closely inward. The territory being explored was physical, the world outside, the place where enemies might gather, or terrain, weather, and other conditions might prove opportunistic for growing or hunting food, building shelter, and so forth. Those times weren’t all that long ago. It was a harsh physical world, not permitting the luxury of inward exploration.

Then, over the past century or more, we did look more inward as a species, taking a particularly hard turn in that direction in the 1960s. This is especially true in Western societies, those that put a premium on individual expression and discovery. Each generation has explored more deeply. It has expanded the territory of human consciousness, the way explorers and pioneers once looked for new lands.

I refer to this newer group of young people as Generation Rumination. They are looking inward at all kinds of things: What is gender anyway? What is a boy? What is a girl? Are they more than social and personal constructs? Which am I? And they are being urged in this direction by forces well beyond their control – biology and neurobiology on one side and a changing environment on the other.

Generation Rumination is growing up in the realm of the mind and psyche. Asking why some are struggling is like asking why some adolescents of yesteryear skinned their knees and broke their bones while trekking over a mountain to explore new terrain.

Just like the physical exploration of unknown lands in centuries past, this probing is not without risks. In the physical world, there could be wounds to the body, natural elements that are hostile and dangerous. This includes physical risks like teen pregnancy, drunk driving injury and death, dangers of binge drinking and smoking.

But those risks have fallen over the past two decades and experimentation and risk-taking in the physical world turned to exploration of the virtual world. This had its own challenges.

The inward-looking explorer can become obsessed, ruminative, and succumb to pressures – real and imagined. This is not everyone. But an overwhelmed mind can be one that is at risk. And this exploration and probing is happening in a particular environment: the Information Age, where the number of ideas, options, opportunities, paths and threats are as loud and voluminous as at any time in history.

There’s not just more opportunity, there’s more threat.

The internet has opened the world, while also transforming the environment in such a way that it contributed to the emergence of a mental health crisis among a generation of adolescents. White noise, competitive information, judgment, lies, and false promises bombarded teenagers and played a role, science shows, in increased feelings of anxiety and depression. Generation Rumination didn’t just look inward, it could become obsessed with dark matters.

A rapidly evolving environment is not the only change impacting adolescence. There is another factor undergoing radical change: the adolescent brain. Adolescence is not only lasting longer, it’s starting earlier. And that’s because of a profound shift in neurobiology.

There has been a significant change to the adolescent brain: the age of puberty is falling.

Two hundred years ago, puberty hit as much as four years later for girls than it does today, and boys experienced roughly the same change. There are a handful of reasons puberty has fallen but a big one is the rise in nutrition; food was once scarce, and thin, undernourished bodies could not handle making a baby and taking care of it. But as food became more readily available, the puberty rate dropped, signalling to bodies that they could make and sustain a new life.

As hormonal changes set in earlier, the transition is causing some adolescents to become highly sensitive to the point of being effectively emotionally paralysed. So much of their time is spent on devices, leading to a collision of a brain under development with technology designed to be addictive and moving at a breakneck pace, and an industry that profits from devouring attention.

What all this leads to is one crucial revelation for some modern adolescents: some are dealing with a neurological mismatch. This is a mismatch between the capabilities of the maturing adolescent brain and the demands of the environment.

Yet adolescents are also like start-up companies in a world that requires new ideas. Their approaches, challenging as they might be to our system, are how individuals survive, and the species perseveres in an uncertain, unpredictable, changing, sometimes hostile environment. Their stories, by definition, are filled with suspense. Each has an ending that feels unpredictable, and most end well. Still, the journey feels perilous right up until it resolves.

I am optimistic about how this all plays out, and the future – even the present – of adolescence. What appears to be a period of chaotic tumult and rebellion appears instead to be a period of life that, by design, helps crack the status quo and push all of us into new directions. The tension they experience internally and bring to society has profound purpose.

This is an edited extract from How We Grow Up: Understanding Adolescence by Matt Richtel, published in Australia by HarperCollins on July 8 (ebook) and July 16 (paperback).

Here is the link:

https://www.theaustralian.com.au/health/mental-health/adolescents-its-time-to-take-back-your-brains/news-story/74322eac52f8d384367d053af49145f5

Looks like a useful contribution to our understanding of growing up – along with ever so many others!

However, remember we all pass though this phase so sit back and observe with interest if you cam. A little benevolent help along the way never hurt!

Davod.

It Seems To Me The Error Prevention Mechanisms In IVF Providers Should Be At The Aeronautical Level Of Integrity And Safety.

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?

Stephen Lunn

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.

Here is the link:

https://www.theaustralian.com.au/health/medical/weird-and-icky-feeling-anxiety-for-parents-after-monash-ivf-embryo-bungles/news-story/c38c936b82a6421d73b160c75d2d730d

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.