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The news of another misplanted embryo at Monash IVF has triggered concerns among patients, and a push for reforms to address shortcomings in care across an $800 million industry. By Hannah Bambra.
The cost of Monash IVF’s mistakes
After losing my first pregnancy, my body ached with grief. It’s a kind of pain I had never felt before, nor thought possible. Then I found myself single, in my 30s and with ovaries that were polycystic.
Among a slew of pink-branded fertility clinics with names like Newlife and No. 1 Fertility, Monash felt like a legitimate and sensible choice when I started my IVF journey two years ago.
The world’s first IVF pregnancy, though short-lived, was achieved by Monash University in 1973. More than 50 years later and now a separate entity, Monash IVF has assisted more than 50,000 births in Australia. Its 2020 campaign “Let’s be brave together” cleverly tapped into the silent hurt that can come with years of trying, suffering loss or finding yourself yearning for a child but unable to have one.
I had felt assured of Monash IVF’s reputation when I first decided to call to discuss a plan to freeze my eggs. I was surprised to be met with many condescending questions about being unpartnered. I had to rely heavily on friends for practical support and I took weeks off work to accommodate wavering hormones, inflexible appointments and last-minute blood tests and ultrasounds. I had to frequently remind staff that my friend would be supporting me, and every form I was given included space for a partner to sign.
The clinic’s recommended specialist also raised my abortion (five years previous and prior to my polycystic ovary syndrome diagnosis) as a reason why I should not receive any financial help. Since I do have a medical reason to use IVF, I was able to receive small Medicare subsidies.
The expense of assisted reproductive technologies (ART) can give people a false sense of security. If you’re paying about $11,000 per round and choosing an established, well-known provider, what could go wrong?
Among all the uncertainties that came up in the process, I saw IVF as an investment for my future self.
Last week, Monash IVF reported that the wrong embryo had been transferred to a patient from their Clayton clinic. The client’s treatment plan had specified for one of their partner’s embryos to be used – one of their own had been transferred instead.
Monash IVF clinical director Dr Gareth Weston told the ABC this week, “Whenever we have human beings involved in a system, there’s a potential for error. And it doesn’t matter how much regulation you have and how many people are supervising it, there are going to be rare instances where that could occur.”
This rare “human error” comes to light only two months after the revelation that a woman from Monash IVF’s Brisbane clinic had given birth to a stranger’s child. The mistake was only discovered when the couple approached Monash to transfer to a different clinic, and an additional embryo was found.
Last week Monash IVF’s chief executive, Michael Knaap, resigned. Health Minister Mark Butler has since said he is worried about public confidence in the sector.
Monash IVF was contacted for comment.
According to the peak body Fertility Society of Australia and New Zealand (FSANZ), approximately 6 per cent of Australian children are currently born through ART and IVF in Australia, and that number is expected to grow significantly over the coming decade. Currently, regulation of the IVF industry varies across the states and territories, and a push is under way for national consistency. The industry is also calling for licensing, registration and staffing levels to be included in legislative reform.
The FSANZ board president, Dr Petra Wale, says its “priority is ensuring that every incident, regardless of where it occurs, is treated seriously, investigated thoroughly, and used to strengthen safety across the entire sector.” However, the industry group’s accreditation body, the Reproductive Technology Accreditation Committee, to which such mistakes are reported, has no consumer voice.
These two announcements in as many months have wide-reaching impacts on the increasing number of people looking to use ART, donor-conceived people, and parents who have already conceived through IVF.
There are implications also for the queer community, who need the rights of donors, surrogates and non-birthing parents to be crystal clear, to protect their families.
“It’s just really disappointing to see. As someone who wants to use surrogacy myself, I’m aware of how delicate it can be and the barriers that exist,” says Morgan Podesta, chair of LGBTQIA+ community organisation Switchboard Victoria and a family lawyer.
“Because of a breakdown in process or human error, there is a lot of uncertainty for the affected families. When starting a family via assisted reproduction, you don’t want to deal with uncertainty from a legal perspective.”
An embryo mistransplant is one of the most catastrophic mistakes that can happen at an IVF clinic, but other careless miscommunications and mistakes seem to be commonplace. Stacey Sinclair’s child, now two and a half, was conceived in another well-known IVF clinic. “Emotionally, it took everything out of me,” she says.
Sinclair and her partner encountered frequent miscommunication in the process and little understanding of how devastating the emotional impact might be. “One of the hardest parts of our cycle came during the embryo stage,” she says. After retrieving three eggs, the wait to see if they would fertilise “nearly broke me”, she remembers.
“At one point, we were told two embryos had made it to day three. Then we got a call saying none had made it. Then another call saying actually, two had survived,” Sinclair says. “That kind of miscommunication – during what is arguably the most fragile time in someone’s life – is not acceptable.”
ART users often imagine IVF to be a highly regulated and trusted process. After years of trying, saving and hoping, it can be difficult to accept anything going wrong on the clinic’s end.
Embryologist and independent fertility educator Lucy Lines has spent 25 years reassuring couples and individuals that mix-ups are almost impossible. “We do everything we can to ensure those things don’t happen,” she says. “But they’re only going to be more of a problem if embryologists are overworked and not getting the breaks and time off they need because clinics are focused on returns to shareholders.”
Her inbox is now full of distraught clients citing their greatest fears, as well as all the times they have been let down by clinics and doctors. “The amount of people who have reached out citing paperwork errors, prescription errors… One woman’s doctor repeatedly called her Amanda when her name was Angela,” says Lines. “Those things will obviously instil fear and distrust. And the best antidote to fear is information.”
Transparency for clients in the IVF sector is crucial, says Georgina Chambers, who is director of UNSW Sydney’s National Perinatal Epidemiology Statistics Unit. “With the increasing corporatisation of the IVF industry, which brings $810 million a year in revenue, it is important to fund and retain independent data and benchmarking. IVF clinics have between a 10 and 35 per cent success rate,” she says.
Lucy Lines is concerned, however, that benchmarking can also get clinics caught up on success rates and statistical chances, possibly incentivising them to “turn away patients who may not have a good response, to discard embryos that have lower chance of pregnancy, to cancel transfers that aren’t good enough quality”.
Lines tries to empower ART-users to ask informed questions. Her three biggest lessons from a career as an embryologist and educator have been that people don’t have enough knowledge about their own reproductive health; GPs know very little about fertility; and infertility is big business.
Jiu* started IVF when she was nearly 40 and went through multiple Sydney-based clinics. After one miscarriage and seven unsuccessful rounds of IVF, Jiu says, she and her then partner were left with a huge amount of unchecked grief. While additional counselling was available, it was left to her to book. “Considering the extremely sensitive nature of information being delivered, the bedside manner of several people at clinics were inconsistent and lacked empathy, tact and timeliness,” she says. “Literally feeling life within you – and then not – over and over. It is deeply existential, on top of feelings of shame and hopelessness and failure.”
Stacey Sinclair says that the way consumers have been treated “shakes the core trust people have in IVF. It creates doubt, uncertainty, and extra stress at a time when people are already incredibly vulnerable. It’s just not good enough. The emotional stakes are too high, and people deserve better.
“I know so many people – friends of mine – who’ve been through round after round, doing everything they possibly can to start a family. Now they’re faced with this added fear that even if they do everything right, something might go wrong on the clinic’s end.”
While these recent announcements may not lead to any changes for people already using IVF, they have served as a platform for ART-users to start sharing the pain and carelessness they have too often encountered in the system.
“We’ve spoken about having more children, but I honestly don’t know if I’d be able to do it,” says Sinclair. “IVF feels like your last hope, and people place enormous trust in the system to protect that. Mistakes like the ones recently reported are a devastating breach of that trust. There has to be better oversight, stronger systems and far more accountability – people deserve nothing less.”
* Name has been changed for privacy.
This article was first published in the print edition of The Saturday Paper on June 21, 2025 as "Human cost of human error".
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