Wrong baby: Systemic failures exposed in Israel’s IVF implant mix-ups

An Israeli hospital has been involved in two cases of implanting embryos into the wrong woman. ELANA SZTOKMAN reports on the messy legal and ethical fallout.

An Israeli woman in advanced stages of pregnancy via in vitro fertilisation (IVF) has discovered by accident that the fetus she is carrying is not biologically her own. No, this is not an episode of Jane the Virgin. This actually happened. And IVF mix-ups are not as rare as one might have hoped.

The woman and her husband had gone through IVF earlier this year at Assuta Hospital in Rishon Letzion, outside of Tel Aviv, using what they believed was their own fertilised embryos. After undergoing genetic testing in her third trimester, she learned that the genes of the fetus do not belong to them.

Assuta immediately opened up an investigation and tracked down approximately 40 women who were going through the process of egg retrieval, fertilisation, freezing and thawing on the same day as the woman in question. Hospital authorities later announced that they believe they found the woman whose embryos were implanted, and that she is not currently pregnant.

They still have not located the embryo of the pregnant woman. They hospital also later announced it believed that the mistake happened at the stage of freezing the embryos.

The Health Ministry immediately established a committee to conduct an investigation and Assuta has since halted all IVF procedures. The committee hit its first snag when the Israeli media discovered that a member of the committee was a doctor who is also on the IVF team at Assuta. After a public outcry, the doctor resigned and the committee resumed its activities.

The story gets worse. An investigative report by Israel TV Channel 12 found that it was not the first time something like this had happened at Assuta. One woman had sued the hospital when she discovered that her embryo was lost and, she suspected, implanted in another woman. The hospital came to an undisclosed financial settlement with the woman, and her suspicions were neither publicly confirmed nor denied. Employees also told reporters they have witnessed negligence in handling embryos.

In the current case, Assuta admitted that the mistake was due to human error.  

But human error is predictable, and countries around the world have mechanisms for protecting patients from this kind of situation. In Australia, for example, this kind of situation is nearly unheard of, according to Dr Genia Rozen, gynaecologist and fertility specialist in Reproductive Services at the Royal Women’s Hospital in Melbourne, and IVF and senior clinical lecturer at the University of Melbourne.

“There are so many mechanisms in place to prevent it from happening,” she told The Jewish Independent, including layers of security at each point. “The entire identification system requires three points of ID at each moment, recording movements in and out at each stage, as well as electronic tagging systems that sound alarms if something goes wrong. Over the years the process has become more and more robust to take the human error factor out of it.”

American infertility expert Amy Klein,  author of The Trying Game: Get Through Fertility Treatment and Get Pregnant Without Losing Your Mind, who underwent IVF both in Israel and America, claims Israel is far behind other countries when it comes to securing the IVF process from these kinds of mistakes. “I visited two IVF labs in Israel and was shocked at how much depends on the people.

“I found the whole system extremely chaotic compared to New York, where I did treatment. At the New York clinics, I had to initial every tissue every step of the way to ensure it was mine and my husband's. During IVF I always had to initial that it was my eggs, my embryos, my sperm.” At the two clinics that she used in Israel, on the other hand, “I did not witness any such checks and balances in place.”

Around the world, strict protocols exist in order to prevent something like this from happening during IVF – including marking, checking, and even signing the materials at every stage of the process. In cases of IVF mix-ups, Klein said, it is usually a case of “not enough attention or checks for the embryo transferred, not enough systems in place for the correct handling of tissue”.

She adds: “when it comes to IVF mix-ups, Israel is far behind the US when it comes to cases we know about”.

In 2015, the European Society of Human Reproduction and Embryology (ESHRE) released a comprehensive set of guidelines for IVF laboratories that recommended strict identification policies in order to avoid human-error mistakes. Dr Karina Sasin, an infertility researcher and writer with ReproAdvice, who works with clinics in Europe, told The Jewish Independent that, as per these guidelines, “identification of patients and traceability of their reproductive cells are crucial aspects of ART treatments.

“Each IVF laboratory must have an effective and accurate system to uniquely identify, trace and locate reproductive cells during each procedural step. A proper identification system should ensure that the main characteristics of patients (or donors) and their tissues and cells, together with relevant data regarding products and materials coming into contact with them, are available at all times.”

It is not clear whether any of the recommended practices are followed in Israel. Klein said that based on her observations: “I would not be surprised if more errors like the ones at Assuta emerge in the coming years.”

It did not take that long. Last week, in a shocking admission, the head of the IVF clinic at Assuta  said  this was already happening. “There is a certain percentage of women who are carrying babies that are not theirs,” he said on the Mako news program.

Israel is often viewed as a “paradise” for women seeking infertility treatments. It is the only country in the world that funds fertility treatments for women up to age 45, and offers unlimited free attempts for women who qualify. Jewish women from around the world struggling with infertility, who qualify for Israeli citizenship, have been known to immigrate to Israel just to benefit from Israel’s generous IVF policies.

Yet, behind that façade, some argue, is a darker reality. Indeed, a commentator in Haaretz claimed that although the story is unusual, the series of events that led up to it is not. Israel’s very aggressive pro-natal culture comes with many hidden risks and costs, argues Sarit Magen, author of the Hebrew-language book, A Child of Your Own: Behind the Curtain of Fertility Treatments in Israel. Israel’s approach may be a bit too eager, aggressive, or single-minded. 

Israel is also the only country that keeps frozen embryos indefinitely. This policy, which is rooted in very conservative notions about whether frozen embryos constitute life, creates a logistical and economic burden on IVF labs, and may contribute to the challenge of maintaining strict order amid millions of embryos.

It’s well-known that IVF can be a physically and emotionally draining experience for couples – and this story exacerbates the anxieties involved.

“The trauma associated with this case is huge and I would hope that any organisation involved would be offering appropriate psychological support to all parties as well as legal and halachic advice (if the relevant parties are Jewish) to ensure that everyone is given the opportunity to come to terms with the reality,” said Justine Saidman, CEO of Australian Jewish Fertility Network (AJFN), that assists Jewish couples in Australia with issues of infertility.

Nitzan Shafir, the legal writer for the Israeli business magazine Globes, asserts that the lawsuits that are sure to result from the Assuta case will be harrowing for all involved. “Legally, the medical negligence is screaming out to the heavens,” Shafir wrote.

“All the sides involved have a claim against the hospital, as well as against other parties, especially considering that the Ministry of Health investigated this issue several years ago and found flaws in the system,” Carmel Ben Tzur, a lawyer for parental rights, told Shafir, although she did not elaborate on the flaws that were found.

The story is devastating for all involved – not just the women, but also all those involved in the medical side and professional side,” according to Dr Genia Rozen. “This is one of the worst things that can happen, and that’s why there are mechanisms in place to prevent it.”

Or at least, there are supposed to be.    

Photo: A scientist picks up a vial containing frozen donor sperm samples in a lab in Melbourne (AP Photo/Wong Maye-E)