This error, which involves the wrongful transfer of the unintended embryo to a mother undergoing ART, could give rise to a claim in medical negligence. This would be a claim for damages for ‘loss of genetic affinity’.

While no such claim has been subject to litigation in Australia before, a well-known case was heard in the Singapore Court of Appeal in 2017. In that case, the parents were successful in suing for a loss of genetic affinity given the expectation by the parents of a genetic connection with their child. Novel legal questions about parentage may also arise in relation to this matter, given that the particular treatment – ie, the use of the third party’s embryo – was not consented to.

Having said all of the above, genetic affinity is not a prerequisite for familial joy; and strong bonds between mother, father and child will no doubt have developed during the conception process. There are thus many difficult decisions to be made in these circumstances.

This situation is devastating for everyone involved. Both sets of parents will be experiencing significant psychological distress – and not only because of questions around parentage. Experiencing infertility and going through IVF can be very tough emotionally and physically in and of itself, as well as expensive - even when things go well. One set of parents has lost an embryo, and one set of parents received an embryo that wasn’t theirs. Both sets of parents have experienced an incredible loss.

For the child, it will be important to consider their best interests, including their right to know about this situation as they grow up.

We should also recognise for the woman who has given birth, this is not a stranger’s baby – she has been pregnant with this child, she gave birth to this child, and raised this child for several months as her own. There is no easy path forward here, but it is not only genetic parenthood that we should think about when we talk about the “biological” or “real” parents – gestational parenthood matters too.

It is the event we fear most in the IVF world. Through our RTAC [The Reproductive Technology Accreditation Committee] accreditation requirements, clinics are obliged to have double witnessing of all times when embryos, eggs and sperm are handled. Hundreds of thousands are spent on electronic systems to support this process. Similar obsessive controls and checkings occur in the aviation industry but sadly planes rarely but still crash. We await the outcome of the Clinic's investigations.

This is truly devastating for everyone involved. I’ve barely slept thinking about how deeply this will be affecting not only the families, but also the clinicians and embryologists who dedicate their lives to this work. It’s hard to comprehend how such an unimaginable error could occur -  particularly in a field where witnessing checks, double-verification, and traceability systems have long been standard practice. In an age where technology plays such a key role in safeguarding every step of the IVF process, this incident is simply unfathomable.

My heart goes first to the families. The emotional weight of this situation is beyond words. But I also find myself thinking about the embryology and clinical teams — the immense distress they must be feeling, and the way this will ripple through their professional and personal lives. Most of us enter this profession with a profound sense of purpose and responsibility. This incident shakes the very foundation of the trust placed in us.

It is a tragic and sobering reminder that even in highly regulated and technologically supported systems, humans are still part of the chain. We must now focus on understanding what happened, supporting those affected, and ensuring it never happens again.

This incident represents an unprecedented occurrence in Australia and remains an exceptionally rare event on a global scale. In-vitro fertilisation (IVF) laboratories and clinics operate within some of the most tightly regulated, meticulously audited environments in all of medicine.

The systems in place are designed with multiple layers of redundancy to ensure the integrity of all procedures involving embryos, oocytes, and sperm. At every critical step—whether during collection, fertilisation, freezing, or transfer—verification by two qualified personnel is mandatory, and electronic tracking systems are widely utilised to further reduce the risk of misidentification.

Australia’s regulatory framework for assisted reproductive technology is internationally recognised for its stringency and thoroughness. Both federal and state-level accreditation bodies maintain rigorous oversight, ensuring high standards of clinical and laboratory practice.

While no system is entirely immune to human error, it is important to emphasise that every conceivable precaution is taken to minimise this risk. Based on the available information, this event is not reflective of a systemic failure, either within the specific clinic involved or across the broader IVF industry.

Rather, this is a highly unusual, “black swan” event—a term used to describe extremely rare occurrences that fall outside the realm of normal expectations. In over four decades of IVF practice in Australia, this is the first recorded incident of its kind. The probability of such an event occurring is so low that it defies statistical quantification; the colloquial phrase 'one in a million' is, in this case, apt.

All those involved in the IVF industry understand and appreciate the concern this may cause among current, former, and future IVF patients, as well as the wider community. However, it is important to provide clear reassurance: the systems currently in place are among the most robust and reliable in the world, and there is every confidence that they will continue to protect against similar events in the future.