EXPERT REACTION: Second IVF mix-up at Monash IVF

This error, which occurred in Victoria, is governed by the state's Assisted Reproductive Treatment Act 2008, a comprehensive legislative framework that has been in place for over a decade. By contrast, the error reported earlier this year at a Monash IVF clinic in Queensland occurred before Queensland's new, more robust ART laws of 2024 became fully operative; previously, the industry in that state operated under what was described as a 'self-regulatory regime'.

Accordingly, this Victorian incident presents a much clearer case where the regulatory authority – now the Secretary for the Department of Health, following the cessation of VARTA's operations at the end of 2024 – can fully exercise established monitoring and disciplinary functions. Critically, the Victorian Act mandates explicit patient consent for the specific kind of treatment procedure. Transferring an embryo different from the one designated in the treatment plan represents a breach of this consent requirement. The Department of Health will undoubtedly investigate whether the clinic's verification and witnessing systems, designed to prevent such human errors, failed.

The Act empowers the Secretary to impose conditions on the ART provider's registration or even suspend it if there are reasonable grounds for doing so, such as a contravention of registration conditions or a clear risk to patient welfare. The Victorian legislation also provides for penalties against designated officers for failures in their duties. This power to hold individuals accountable underscores the Department of Health's crucial role in ensuring patient safety and upholding public confidence in ART services in Victoria.

This recent episode, where a mix-up of embryos has occurred, is incredibly saddening. I feel for all concerned, especially the patients, but also the embryologists involved.

Being an embryologist places high demands on skills and concentration and can be stressful, particularly in busy laboratories, where skill and time management are critical for the best outcome from applying the multiple procedures conducted in the laboratory.

Globally, there is a shortage of well-trained and experienced embryologists, and as such, levels of training and experience can vary. Australia’s reputation as a leader in embryology training and technique auditing is beyond question.

Although there is not yet formal accreditation of embryologists in Australia, auditing is conducted through an arm of the Fertility Society of Australia and New Zealand, along with professional development programs conducted in states and nationally.

Continued mishappenings in IVF are of serious concern to patients, and it calls for more rigorous compliance required for this industry. 

While in New Zealand, Embryologists are registered with the Health Practitioners Competence Assurance Act, there is no such provision in Australia for embryologists, and they are not currently registered under a national scheme.  This would help in adding another layer of responsibility to check such mishappenings in the IVF industry. Although NATA oversees the IVF industry in Australia, more stringent management for inventory is required to minimise the risk of mix-up by implementing ISO 9001 system more rigorously.

In reproductive care, trust is everything. Patients entrust clinics with embryos that may represent their only opportunity to have children. This mix-up - the second reported incident at Monash IVF - risks shaking confidence not just in one provider, but across the entire fertility sector. As more and more people are turning to commercial IVF providers when they make reproductive decisions, we need consistency and oversight in regulation across Australia. Accountability and transparency are critical to maintain trust.

The report of a second embryo transfer error is profoundly troubling and, while still extremely rare, shifts this issue from an isolated anomaly to one demanding broader reflection.

IVF clinics operate within some of the most highly regulated and scrutinised environments in medicine. Multiple safeguards—including dual verification and electronic tracking—exist at every step to prevent precisely this kind of error. Australia’s assisted reproduction sector is internationally recognised for its rigorous oversight and quality control.

Although human error can never be entirely eliminated, incidents like this are not indicative of widespread system failure. Instead, they highlight the need to review how even robust systems respond to rare but serious breaches.

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.

This should prompt open investigation, continued transparency, and renewed commitment to patient safety. Australians can remain confident that the systems governing IVF are strong, and that they will continue to evolve in response to emerging challenges.

The news that another woman in Australia has had the wrong embryo transferred in an IVF procedure is likely to cause a lot of discomfort among other clients of assisted reproductive services, both here and overseas. Many of us feel immediate sympathy for the individuals involved and the complicated feelings this incident may have caused.

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 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.

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.