Let's get more now on that IVF mix up with reproductive specialist, associate professor, Alex Polyakov. He says it's a strange situation as there are a number of checks that occur during the IVF process.
Category
📺
TVTranscript
00:00The process of IVF takes place from the beginning of a cycle when stimulation is given, and
00:08then eggs are collected.
00:11Those eggs are placed in dishes which are clearly labelled with what we call three-point
00:16ID.
00:17So the patient's name, address, date of birth, and the clinic number are all on the dish
00:22where the eggs are stored.
00:24They go to the lab and they are fertilized with usually partner sperm but sometimes donor
00:32sperm and those ID badges are transferred from one dish to another.
00:37So when an embryo is moved, it can only be moved from one dish to another where those
00:42three points of ID are checked and the checks usually involve two embryologists who look
00:47at all those data points and confirm that the embryo actually belongs to that particular
00:53patient.
00:54So usually one embryo is transferred and the rest are frozen, which is what seems to have
00:58happened in this case.
01:00And then once they need to be used, they are pulled from a freezing tank and the straws in
01:07which they are frozen are also labelled in the same fashion.
01:11And every step of the way, there are two embryologists or two scientists who look at all those points
01:17of identification and confirm that the embryo belongs to that particular patient.
01:21So an embryo is thawed and transferred into a dish, which once again has all those points
01:26of identification and in some clinics there is also electronic tagging of those dishes.
01:32So there is an electronic record as to from which dish an embryo is taken.
01:38And then embryo is taken into the embryo transfer room and put into a pipel and transferred into
01:44a patient's uterus and hopefully produces a pregnancy.
01:47So there are redundancies upon redundancies.
01:50So this sort of situation doesn't happen.
01:52There are at least two embryologists involved at every step of the way confirming the identity
01:58of the embryo, sperm and eggs, and linking those to the identity of a particular patient.
02:04Yeah, so that key backup system that you mentioned there is the two embryologists.
02:10Does this case indicate that maybe that something needs to change, something else needs to be added
02:16to that process?
02:19Well, I think it's important to know that this is a unique situation.
02:23I mean, IVF has been around in Australia for about 40 years.
02:27At the moment, we will probably do about 120,000 to 150,000 embryo transfers a year.
02:34And this is the first instance where a child was born from a wrong embryo.
02:41And so I think the system is robust.
02:45There are always two people who are involved in the identification.
02:49And I am not entirely clear as to how this happened.
02:53I can't really comment on that because the details haven't been released.
02:56And I understand there are a number of investigations going on.
02:59But I would say that the current system actually works very well.
03:03Unfortunately, there are humans involved in this process.
03:07And very, very rarely, probably one in a million or so, there are mistakes that are made.
03:13And Monasheviev themselves put it down to human error, which I think that's what it was.
03:18But we have to wait for the results of the investigations to come out to determine what actually happened
03:24in this particular instance.
03:26Does the sector have a code where there are protocols set out of what's required through
03:32the system?
03:34Absolutely.
03:35I mean, IVF sector is probably the most regulated sector in medicine in Australia.
03:39We have a very robust regulatory framework.
03:43It's on the federal and state level.
03:45And each state has their own regulator.
03:47In Queensland, that has changed recently, I understand.
03:50But nevertheless, there are very robust protocols.
03:53And one of the key points to be made is that all of Australia, every clinic, must have two
04:01people identifying and checking the identity of the either gametes or embryos and matching
04:06them to the patient.
04:08Furthermore, when the embryo transfer actually takes place, the patient is involved in that
04:13process as well.
04:13So we take a dish which contains the embryo.
04:17We ask the patient, what's your name, address and date of birth?
04:20And then electronically, we check their patient number and it must match to the number on the
04:27dish.
04:28So, yes, there was some sort of an error that resulted in this very, very unfortunate incident.
04:35But I am not quite clear what else can be done to prevent those errors in the future.
04:42Doesn't the fact this was only discovered by chance after the birth parents asked to transfer
04:46their remaining eggs to another provider suggest that maybe this could have happened before
04:52without anyone realising?
04:55It's very difficult to answer that question.
04:57I think the processes, once again, that guide these technologies are extremely robust in
05:06Australia.
05:07We can't say whether this happened before or not.
05:10But to my knowledge, in Australia, this is the first instance where this has happened.
05:15And the baby was born from a wrong embryo.
05:18There were some reports in years gone by where there were similar instances in other countries
05:24like United States and Israel more recently.
05:26But this is, you know, it's world news.
05:30It happens so very rarely.
05:32And we transfer so many embryos that my feeling is that the chance of this happening is exceedingly
05:39low.
05:40This is obviously incredibly traumatic.
05:42Would you expect there'll have to be some substantial payment made as compensation to the
05:48couples involved?
05:50Well, I think that goes a little bit beyond my area of expertise.
05:55I'm not a lawyer.
05:58You would think that the lawyers would jump onto this one.
06:01But I don't know what the outcome will be.
06:04There are a lot of ethical and legal questions associated with this particular scenario, which
06:11you perhaps want to speak with an ethicist or a lawyer who specialises in this area.
06:17OK, and so broadly then, how should people feel about IVF standards here in Australia in
06:22the wake of this?
06:24I would have to say that the IVF standards in Australia are among the highest in the world,
06:28if not the highest.
06:30And so I would urge people not to panic.
06:36And I would say that this sort of scenario, what actually happened in this instance, is
06:42unique.
06:43I mean, it's not something that is a systemic problem within the industry or even that particular
06:48clinic.
06:49I think it's a very unfortunate confluence of events, which resulted in this outcome.
06:57But overall, I would like to reassure future patients and current patients and former patients
07:03of IVF clinics that this scenario is exceedingly unlikely.
07:07And it's unlikely that it's happening on a wider scale rather than, you know, just a unique
07:15occurrence that happened here.